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STATE OF ILLINOIS

Health Care Professional Credentialing and Business Data Gathering Form

The Health Care Professional Credentials Data Collection Act [410 ILCS 517] requires that this form be collected from health care professionals by hospitals, health care entities, and health care plans which desire to credential such professional. Each hospital, health care entity, and health care plan may also require completion of supplemental forms.

INSTRUCTIONS

This form is for initial credentialing only. Other forms are required for recredentialing and for updating information. YOU ONLY HAVE TO FILL OUT AND SUBMIT WHAT IS REQUESTED BY THE CREDENTIALING ENTITY. PLEASE REFER TO THE INSTRUCTIONS PROVIDED TO YOU BY THE ORGANIZATION YOU ARE APPLYING TO FOR THEIR REQUIREMENTS.

This form has been segmented into two (2) different Chapters, each containing various sections:

Chapter A: Practice and Professional Information

Chapter B: Business Information

As previously noted, please consult the specific credentialing entity instructions for their individual Chapter or Section requirements for submission.

GENERAL INSTRUCTIONS: Wherever this application requests information but does not provide sufficient space to provide a complete response (for example, you have more licenses, specialties, work history, etc.) provide attachments which contain all of the information requested in the relevant section OR duplicate the relevant section as many times as necessary and attach it to the back of this application.

The data marked as “Confidential Information” shall be maintained in confidence to the extent required by law. They may be used by the health care plan, entity or hospital and by their agents for credentialing and internal business purposes. Other data contained in this form may be released.

Health Care Professionals Credentialing & Business Data Gathering Form	1
Applicant Name:

ATTACHMENTS

Attach forms A-F as needed to support “yes” responses in Section J: Professional History and copies of the following:

Curriculum Vitae

CONFIDENTIAL INFORMATION:

All Current Professional Licenses

Current Federal DEA License, If Applicable

Current State Controlled Substance License(s), If Applicable

Current Professional Liability Insurance Face Sheet or Declaration of Insurance with

Effective Date, Expiration Date and Amount Displayed per Occurrence and In

Aggregate

Current CLIA Certificate, If Applicable

Current W-9s, If Applicable

ECFMG Certificate, If Applicable

Professional School Diploma, Residency Certificates, Fellowship Certificates, and

Board Certifications, As Applicable

AFFIRMATION OF INFORMATION

I represent and warrant that all of the information provided and the responses given are correct and complete to the best of my knowledge and belief. I understand that falsification or omission of information may be grounds for rejection or termination, in addition to any penalties provided by law. I further agree to promptly inform all entities to which this form was sent and not rejected of any change required to be updated by the Health Care Professional Credentialing and Business Data Gathering Update Form.

I understand that this application does not entitle me to participation in any hospital, health care entity, or health plan.


Applicant’s Signature		Type or Print Name	Date
** PLEASE BE ADVISED THAT EACH HOSPITAL, HEALTH CARE ENTITY,				**
** AND HEALTH CARE PLAN MAY ALSO REQUIRE COMPLETION OF AN				**
**	ATTESTATION AND RELEASE OF INFORMATION FORM.			**

Health Care Professionals Credentialing & Business Data Gathering Form	2
Applicant Name:

CHAPTER A:

PRACTICE AND PROFESSIONAL INFORMATION

SECTION A. GENERAL INFORMATION

Name:

LastFirstMI Degree

List other names by which you have been known:

Last

First

If you have been known by other names, please explain why your name changed:

Birth Date:		Place of Birth:
	(mm/dd/yy)		City	State	Country

Sex:	Male		Female	Language Fluency of Applicant:	English	Other:
U.S. Citizen?		Yes	No		Spanish
		If no, do you have a legal right to reside permanently and work in the U.S.?					Yes

Resident Visa No:

Social Security Number:

Emergency Contact Person:

CONFIDENTIAL INFORMATION

		Last					First		MI

		Telephone Number:			(	)


Mailing Address:
	Street						City	State	Zip
Daytime Phone: ( )			Fax Number: (	)

E-Mail Address:

Check here if you have appended additional information for this section:

(Please continue next page)

Health Care Professionals Credentialing & Business Data Gathering Form	3
Applicant Name:

SECTION B. PROFESSIONAL INFORMATION

Illinois Professional License Number:

License Unlimited? Yes

If No, please explain limitation:

Current and Previous Professional License(s) in Other States
State:			License #:				Exp. Date:	(mm/dd/yy)

	License Unlimited?	Yes		No	If No, please explain limitation:

State:			License #:				Exp. Date:	(mm/dd/yy)

	License Unlimited?	Yes		No	If No, please explain limitation:

State:			License #:				Exp. Date:	(mm/dd/yy)

	License Unlimited?	Yes		No	If No, please explain limitation:

Check here if you have appended additional information for this section:

Current Federal DEA License Number:						CONFIDENTIAL INFORMATION

DEA License Number Expiration Date:

License Unlimited? Yes

If No, please explain limitation:

Check here if you have appended additional information for this section:

Current and Previous State Controlled Substance Number(s):

CONFIDENTIAL INFORMATION

State:	CS License #:	Expiration Date:
			(mm/dd/yy)
State:	CS License #:	Expiration Date:
			(mm/dd/yy)
State:	CS License #:	Expiration Date:
			(mm/dd/yy)

Please identify all limitation related to the above Controlled Substances Number(s) and explain limitation.

Health Care Professionals Credentialing & Business Data Gathering Form	4
Applicant Name:

Medicare Unique Provider ID# (UPIN):

National Provider Identification Number (NPI):

Medicaid ID#:

X-Ray Certification: State:

Certificate #:

Expiration Date:

(mm/dd/yy)

Check here if you have appended additional information for this section:

COMPLETE FOR EACH SPECIALTY

Specialty I:

Are you Board Certified in Specialty I?

Yes

If Yes, name of Certifying Board:

Date of Certification:

Date of Recertification (if applicable):

(mm/yy)

If No, have you taken or are you scheduled to take the specialty boards certification?

Yes

If Certifying Boards taken, give date:

Certification Expiration Date, if Any:

(mm/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/yy)

Specialty/Subspecialty II:

Are you Board Certified in Specialty II?

Yes

If Yes, name of Certifying Board:

Date of Certification:

Date of Recertification (if applicable):

(mm/yy)

If No, have you taken or are you scheduled to take the specialty boards certification?

Yes

If Certifying Boards taken, give date:

Certification Expiration Date, if Any:

(mm/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/yy)

(Please continue next page)

Health Care Professionals Credentialing & Business Data Gathering Form	5
Applicant Name:

Specialty/Subspecialty III:

Are you Board Certified in Specialty III?

Yes

If Yes, name of Certifying Board:

Date of Certification:

Date of Recertification (if applicable):

(mm/yy)

If No, have you taken or are you scheduled to take the specialty boards certification?

Yes

If Certifying Boards taken, give date:

Certification Expiration Date, if Any:

(mm/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/yy)

Specialty/Subspecialty IV:

Are you Board Certified in Specialty IV?

Yes

If Yes, name of Certifying Board:

Date of Certification:

Date of Recertification (if applicable):

(mm/yy)

If No, have you taken or are you scheduled to take the specialty boards certification?

Yes

If Certifying Boards taken, give date:

Certification Expiration Date, if Any:

(mm/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/yy)

Check here if you have appended additional information for this section:

(Please continue next page)

Health Care Professionals Credentialing & Business Data Gathering Form	6
Applicant Name:

SECTION C. PROFESSIONAL LIABILITY INSURANCE

Please provide information on all professional liability insurance carriers from whom you have received coverage in the past 10 years.

CURRENT PROFESSIONAL LIABILITY INSURANCE

CONFIDENTIAL INFORMATION:

Carrier:

Address:

StreetCityState Zip

Policy Number:		Original Effective Date:		Expiration Date:
			(mm/dd/yy)		(mm/dd/yy)

Has any judgment or payment of claim or settlement amount exceeded the limits of this coverage?

Yes

PREVIOUS PROFESSIONAL LIABILITY INSURANCE

CONFIDENTIAL INFORMATION:

Carrier:

Address:

StreetCityState Zip

Policy Number:		Original Effective Date:		Expiration Date:
			(mm/dd/yy)		(mm/dd/yy)

Has any judgment or payment of claim or settlement amount exceeded the limits of this coverage? Yes

Health Care Professionals Credentialing & Business Data Gathering Form	7
Applicant Name:

PREVIOUS PROFESSIONAL LIABILITY INSURANCE

CONFIDENTIAL INFORMATION:

Carrier:

Address:

StreetCityState Zip

Policy Number:		Original Effective Date:		Expiration Date:
			(mm/dd/yy)		(mm/dd/yy)

Has any judgment or payment of claim or settlement amount exceeded the limits of this coverage?

Yes

PREVIOUS PROFESSIONAL LIABILITY INSURANCE

CONFIDENTIAL INFORMATION:

Carrier:

Address:

StreetCityState Zip

Policy Number:		Original Effective Date:		Expiration Date:
			(mm/dd/yy)		(mm/dd/yy)

Has any judgment or payment of claim or settlement amount exceeded the limits of this coverage? Yes

Health Care Professionals Credentialing & Business Data Gathering Form	8
Applicant Name:

SECTION D. EDUCATION AND TRAINING

If there are any gaps in your training (greater than 30 days), or if you have not completed any portion of your training, please explain on a separate sheet of paper and attach to this application.

MEDICAL/PROFESSIONAL SCHOOL

Institution Name:

Mailing Address:

Street

City

State Zip

Telephone Number: ( )

Fax Number: ( )

Degree:

Year Graduated:

Dates attended: From:

To:

mm/yy

If you are a graduate of a foreign medical school, are you certified by the Educational Commission for Foreign

Medical Graduates (ECFMG)?		Yes	No
Date Issued:			Serial Number for ECFMG:
	mm/yy
Were you the subject of any disciplinary action during your attendance at this institution?				Yes	No
(Attach an explanation of a “Yes” answer.)

If you attended more than one medical/professional school, please check here and attach an explanation that duplicates the information requested above:

INTERNSHIP

Institution Name:

Department Chair or Program Director:

Last NameFirst Name MI Degree

Mailing Address:

Street

City

State

Zip

Telephone Number: (

)

Fax Number: (

)

Dates attended: From:

To:

mm/yy

Type of internship:

Rotating

Straight

If straight, please list specialty:

Did you successfully complete this program?

Yes

If no, please attach an explanation.

Were you the subject of any disciplinary action during your attendance at this institution?

Yes

(Attach an explanation of a “Yes” answer.)

If more than one internship, please check here and attach additional information that duplicates the information requested above:

Health Care Professionals Credentialing & Business Data Gathering Form	9
Applicant Name:

FIRST RESIDENCY

Institution Name:

Department Chair or Program Director:

Last NameFirst Name MI Degree

Mailing Address:

Street

City

State

Zip

Telephone Number: ( )

Fax Number: (

)

Dates attended: From:

To:

mm/yy

Type of residency:

Did you successfully complete this program?

Yes

If no, please attach an explanation.

Were you the subject of any disciplinary action during your attendance at this institution?

Yes

(Attach an explanation of a “Yes” answer.)

SECOND RESIDENCY

Institution Name:

Department Chair or Program Director:

Last NameFirst Name MI Degree

Mailing Address:

StreetCityState Zip

Telephone Number: ( )

Fax Number: (

)

Dates attended: From:

To:

mm/yy

Type of residency:

Did you successfully complete this program?

Yes

If no, please attach an explanation.

Were you the subject of any disciplinary action during your attendance at this institution?

Yes

(Attach an explanation of a “Yes” answer.)

If more than two residencies, please check here and attach additional information that duplicates the information requested above:

(Please continue next page)

Health Care Professionals Credentialing & Business Data Gathering Form	10
Applicant Name:

FIRST FELLOWSHIP

Institution Name:

Department Chair or Program Director:

Last NameFirst Name MI Degree

Mailing Address:

Street

City

State

Zip

Telephone Number: ( )

Fax Number: (

)

Dates attended: From:

To:

mm/yy

Type of fellowship:

Did you successfully complete this program?

Yes

If no, please attach an explanation.

Were you the subject of any disciplinary action during your attendance at this institution?

Yes

(Attach an explanation of a “Yes” answer.)

SECOND FELLOWSHIP

Institution Name:

Department Chair or Program Director:

Last NameFirst Name MI Degree

Mailing Address:

StreetCityState Zip

Telephone Number: ( )

Fax Number: (

)

Dates attended: From:

To:

mm/yy

Type of fellowship:

Did you successfully complete this program?

Yes

If no, please attach an explanation.

Were you the subject of any disciplinary action during your attendance at this institution?

Yes

(Attach an explanation of a “Yes” answer.)

If more than two fellowships, please check here and attach additional information that duplicates the information requested above:

(Please continue next page)

Health Care Professionals Credentialing & Business Data Gathering Form	11
Applicant Name:

TEACHING EXPERIENCE/FACULTY APPOINTMENT (MOST RECENT)

Institution Name:

Department Chair or Program Director:

Last NameFirst Name MI Degree

Mailing Address:

Street

City

State Zip

Telephone Number: (

)

Fax Number: ( )

Dates: From:

To:

Rank/Position, if applicable:

mm/yy

Were you the subject of any disciplinary action during your attendance at this institution?	Yes
(Attach an explanation of a “Yes” answer.)

TEACHING EXPERIENCE/FACULTY APPOINTMENT (PREVIOUS)

Institution Name:

Department Chair or Program Director:

Last NameFirst Name MI Degree

Mailing Address:

Street

City

State Zip

Telephone Number: (

)

Fax Number: ( )

Dates: From:

To:

Rank/Position, if applicable:

mm/yy

Were you the subject of any disciplinary action during your attendance at this institution? (Attach an explanation of a “Yes” answer.)

Yes

If more than two teaching experiences/faculty appointments, please check here and attach additional information that duplicates the information requested above:

(Please continue next page)

Health Care Professionals Credentialing & Business Data Gathering Form	12
Applicant Name:

MEMBERSHIP STATUS – USE FOR SECTIONS E, F, AND G

Please use the following key to indicate membership status in Sections E (Hospital Membership – Current and Pending), F (Hospital Membership – Previous), and G (Ambulatory Surgery Center Practice) below.

A.Active

B.Courtesy

C.Consulting

D.Adjunct

E. Suspended / Terminated/ Resigned

F. Active Provisional Staff

G. Senior Staff

H. Associate

I.Provisional

J.Affiliate

K.Pending

L.Other (Specify)

SECTION E. HOSPITAL MEMBERSHIP - CURRENT AND PENDING

Please list all hospitals at which you are a member of the Medical Staff and have clinical privileges or have applications for privileges pending. (Include additional sheets if more than three hospitals.)

A. Primary Hospital

Hospital Name:

Address:

StreetCityState Zip

Membership Status:

Dates:

To Present

From (mm/yy)

Department/Division:

Medical Staff Office FAX #: (

)

Department Telephone #: (

)

Any Limitations in Your Area of Specialty at this Hospital?

B. Other Hospital

Hospital Name:

Address:

Street

City

State

Zip

Membership Status:

Dates:

To:

From (mm/yy)

To (mm/yy)

Department/Division:

Medical Staff Office FAX #: (

)

Department Telephone #: (

)

Any Limitations in Your Area of Specialty at this Hospital?

Health Care Professionals Credentialing & Business Data Gathering Form	13
Applicant Name:

C. Other Hospital

Hospital Name:

Address:

StreetCityState Zip

Membership Status:

Dates:

To:

From (mm/yy)

To (mm/yy)

Department/Division:

Medical Staff Office FAX #: ( )

Department Telephone #: (

)

Any Limitations in Your Area of Specialty at this Hospital?

Check here if you have appended additional information for this section:

SECTION F. HOSPITAL MEMBERSHIP – PREVIOUS

Please list all hospitals where you previously held privileges other than during your Internship/Residency/Fellowship. Use the Membership Status key listed prior to Section E. (Include additional sheets if more than three hospitals.)

A. Hospital Name:

Address:

StreetCityState Zip

Membership Status:

Dates:

To:

From (mm/yy)

To (mm/yy)

Department/Division:

Medical Staff Office FAX #: ( )

Department Telephone #: (

)

Any Limitations in Your Area of Specialty at this Hospital?

B. Hospital Name:

Address:

StreetCityState Zip

Membership Status:

Dates:

To:

From (mm/yy)

To (mm/yy)

Department/Division:

Medical Staff Office FAX #: ( )

Department Telephone #: (

)

Any Limitations in Your Area of Specialty at this Hospital?

Health Care Professionals Credentialing & Business Data Gathering Form	14
Applicant Name:

C. Hospital Name:

Address:

StreetCityState Zip

Membership Status:

Dates:

To:

From (mm/yy)

To (mm/yy)

Department/Division:

Medical Staff Office FAX #: ( )

Department Telephone #: (

)

Any Limitations in Your Area of Specialty at this Hospital?

Check here if you have appended additional information for this section:

SECTION G. AMBULATORY SURGERY CENTER PRACTICE

Please list all ambulatory surgery centers where you currently have or previously had privileges. Use the Membership Status key at the top of page 13. (Include additional sheets if more than three ambulatory surgery centers.)

A.Primary Ambulatory Surgery Center ASC Name:

Address:

Street			City			State Zip
Telephone: ( )	Fax Number: ( )

Membership Status:		Dates:			To:
				From (mm/yy)		To (mm/yy)

B.Other Ambulatory Surgery Center ASC Name:

Address:

Street			City			State Zip
Telephone: ( )	Fax Number: ( )

Membership Status:		Dates:			To:
				From (mm/yy)		To (mm/yy)

C.Other Ambulatory Surgery Center ASC Name:

Address:

Street			City			State Zip
Telephone: ( )	Fax Number: ( )

Membership Status:		Dates:			To:
				From (mm/yy)		To (mm/yy)

Check here if you have appended additional information for this section:

Health Care Professionals Credentialing & Business Data Gathering Form	15
Applicant Name:

SECTION H. WORK HISTORY

List chronologically (most recent first) all work engagements (including employment, self- employment, service as an independent contractor, and military service). Do not duplicate internship, residency, and fellowship information previously reported. If there is any gap of greater than 30 days in chronology, explain it on a separate page.

Current work place:

Address:

Street

City

State

Zip

Telephone: (

)

Fax Number: (

)

Title or Professional Occupation:

Time in this employment: From:

to Present

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone: (

)

Fax Number: (

)

Title or Professional Occupation:

Time in this employment: From:

to:

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone: (

)

Fax Number: (

)

Title or Professional Occupation:

Time in this employment: From:

to:

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone: (

)

Fax Number: (

)

Title or Professional Occupation:

Time in this employment: From:

to:

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone: (

)

Fax Number: (

)

Title or Professional Occupation:

Time in this employment: From:

to:

(mm/yy)

Health Care Professionals Credentialing & Business Data Gathering Form

Applicant Name:

Previous work place:

Address:

Street

City

State

Zip

Telephone: (

)

Fax Number: (

)

Title or Professional Occupation:

Time in this employment: From:

to:

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone: (

)

Fax Number: (

)

Title or Professional Occupation:

Time in this employment: From:

to:

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone: (

)

Fax Number: (

)

Title or Professional Occupation:

Time in this employment: From:

to:

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone: (

)

Fax Number: (

)

Title or Professional Occupation:

Time in this employment: From:

to:

(mm/yy)

Check here if you have appended additional information for this section:

(Please continue next page)

Health Care Professionals Credentialing & Business Data Gathering Form	17
Applicant Name:

SECTION I. PROFESSIONAL REFERENCES

Please list the names of three individuals who have personal knowledge (within the past 12 months) of your current clinical abilities, ethical character and interpersonal skills and who would be willing to provide this information upon request. Do not list partners or department chairpersons. Do not list relatives or people listed elsewhere in this credentialing form.

CONFIDENTIAL INFORMATION

Name:

Title:

Last

First

Degree

Specialty:

Mailing Address:

Street

City

State

Zip

Telephone: (

)

Fax Number: (

)

Relationship:

Years Known:

Name:

Title:

Last

First

Degree

Specialty:

Mailing Address:

Street

City

State

Zip

Telephone: (

)

Fax Number: (

)

Relationship:

Years Known:

Name:

Title:

Last

First

Degree

Specialty:

Mailing Address:

Street

City

State

Zip

Telephone: (

)

Fax Number: (

)

Relationship:

Years Known:

(Please continue next page)

Health Care Professionals Credentialing & Business Data Gathering Form	18
Applicant Name:

SECTION J. PROFESSIONAL HISTORY: CONFIDENTIAL

ADVERSE OR OTHER ACTIONS

Submit with all applications. Please answer the following questions to the best of your knowledge with a “yes” or “no.” If you answer “yes” to any question(s) please complete Form A. Please make copies of Form A as needed and complete one form for each “yes” answer.

1.Has your license to practice in any jurisdiction ever been denied, restricted, limited, suspended, revoked, canceled and/or subject to probation either voluntarily or involuntarily, or has your application for a license ever been withdrawn?

2.Have you ever been reprimanded and/or fined, been the subject of a complaint and/or have you been notified in writing that you have been investigated as the possible subject of a criminal, civil or disciplinary action by any state or federal agency which licenses providers?

3.Have you lost any board certification(s), and/or failed to recertify?

4.Have you been examined by a Certifying Board but failed to pass?

5.Has any information pertaining to you, including malpractice judgments and/or disciplinary action, ever been reported to the National Practitioner Data Bank (NPDB) and/or any other practitioner data bank?

6.Has your federal DEA number and/or state controlled substances license been restricted, limited, relinquished, suspended or revoked, either voluntarily or involuntarily, and/or have you ever been notified in writing that you are being investigated as the possible subject of a criminal or disciplinary action with respect to your DEA or controlled substance registration?

7.Have you, or any of your hospital or ambulatory surgery center privileges and/or membership been denied, revoked, suspended, reduced, placed on probation, proctored, placed under mandatory consultation or non-renewed?

8.Have you voluntarily or involuntarily relinquished or failed to seek renewal of your hospital or ambulatory surgery center privileges for any reason?

9Have any disciplinary actions or proceedings been instituted against you and/or are any disciplinary actions or proceedings now pending with respect to your hospital or ambulatory surgery center privileges and/or your license?

10.Have you ever been reprimanded, censured, excluded, suspended and/or disqualified from participating, or voluntarily withdrawn to avoid an investigation, in Medicare, Medicaid, CHAMPUS and/or any other governmental health-related programs?

11.Have Medicare, Medicaid, CHAMPUS, PRO authorities and/or any other third party payors brought charges against you for alleged inappropriate fees and/or quality-of- care issues?

Yes

Yes Yes

Yes

Health Care Professionals Credentialing & Business Data Gathering Form	19
Applicant Name:

12.Have you been denied membership and/or been subject to probation, reprimand, sanction or disciplinary action, or have you ever been notified in writing that you are being investigated as the possible subject of a criminal or disciplinary action by any health care organization, e.g. hospital, HMO, PPO, IPA, professional group or society, licensing board, certification board, PSRO, or PRO?

13.Have you withdrawn an application or any portion of an application for appointment or reappointment for clinical privileges or staff appointment or for a license or membership in an IPA, PHO, professional group or society, health care entity or health care plan prior to a final decision to avoid a professional review or an adverse decision?

Yes

PROFESSIONAL LIABILITY ACTIONS

If you answer yes to any question(s) in this section please complete FORM B. Please make copies of FORM B if needed, and complete one for each yes answer.

1. Have any professional liability judgments ever been entered against you?

Yes

2.Have any professional liability claim settlements ever been paid by you and/or paid on

your behalf?

Yes

3.Are there any currently pending professional liability suits, actions and/or claims filed

against you?	Yes
4. Has any person or entity ever been sued for your clinical actions?	Yes

LIABILITY INSURANCE

If you answer yes to this question please complete FORM C.

Have you ever been denied or voluntarily relinquished your professional liability insurance coverage, and/or have had your professional liability insurance coverage canceled, non- renewed or limits reduced ?

Yes

CRIMINAL ACTIONS

If you answer yes to any question(s) in this section please complete FORM D. Please make copies of FORM D if needed, and complete one for each yes answer.

1.Have you been charged with or convicted of a crime (other than a minor traffic offense) in this or any other state or country and/or do you have any criminal charges pending other than minor traffic offenses in this state or any other state or country?

2.Have you been the subject of a civil or criminal complaint or administrative action or been notified in writing that you are being investigated as the possible subject at a civil, criminal or administrative action regarding sexual misconduct, child abuse, domestic violence or elder abuse?

Health Care Professionals Credentialing & Business Data Gathering Form

Applicant Name:

Yes

MEDICAL CONDITION

If you answer yes to this question please complete FORM E.

Do you have a medical condition, physical defect or emotional impairment which in any way impairs and/or limits your ability to practice medicine with reasonable skill and safety?

Yes

CHEMICAL SUBSTANCES OR ALCOHOL ABUSE

If you answer yes to any question(s) in this section please complete FORM F. Please make copies of FORM F if needed, and complete one for each yes answer.

1.Are you currently engaged in illegal use of any legal or illegal substances?

2.Do you currently overuse and/or abuse alcohol or any other controlled substances?

3.If you use alcohol and/or chemical substances, does your use in any way impair and/or limit your ability to practice medicine with reasonable skill and safety?

4.Are you currently participating in a supervised rehabilitation program and/or professional assistance program which monitors you for alcohol and/or substance abuse?

Yes Yes

Yes

No No

INVESTMENTS

In the last five (5) years have you and/or a member of your family purchased or made an investment in (other than securities of a publicly traded company), or otherwise have a business interest in any clinical laboratory, diagnostic or testing center, hospital, surgicenter, and/or other business dealing with the provision of ancillary health services, equipment or supplies?

If Yes, please provide explanation:

Yes

(Please continue next page)

Health Care Professionals Credentialing & Business Data Gathering Form	21
Applicant Name:

CHAPTER B:

BUSINESS INFORMATION

SECTION K. PRIMARY SITE INFORMATION

Please provide the following information for the primary site at which you practice.

Primary

Site

Group/Business Name

Building Name

Office Address – Number and Street – Suite

City					County		State	Zip
(	)
Main Telephone Number			Office Administrator – Last				First	MI
(	)	(		)
Beeper Number			FAX Number			E-mail
(	)	(		)
Emergency Number			Answering Service

Specialty practiced at this site:

Is your practice restricted within your specialty (e.g., by age or type of patient)? If yes, describe the restrictions:

Yes

Briefly describe your practice at this location, including any special practice focus or equipment:

Are you currently accepting new patients at this location?	Yes	No
If yes, describe any restrictions (e.g., appointment type, patient type):

Please provide the number of active patients enrolled with you at this site:

Please provide the number of patient visits you have at this site per year:

Indicate your office schedule at this location in the following table. Write your specific hours in the appropriate spaces for each day:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday

Hours
	to	to	to	to	to	to	to

Health Care Professionals Credentialing & Business Data Gathering Form							22
Applicant Name:

Please indicate standard patient waiting times to schedule an appointment at this site for:

New Patient Existing Patient

Emergency Care

Urgent Care

Symptomatic Care (e.g., sore throat)

Routine Visits (e.g., blood pressure check)

Preventive Routine Care (e.g., school or annual physical)

Please provide the following regarding your practice at this site:

Maximum Number of Appointments per Hour

Average Waiting Time in Office (from scheduled appointment time to actual examination)

Average Response Time for Returning Acute or Urgent Situation:

Patient Calls:

Emergency Situation:

Routine Call:

Please check all procedures you perform at this site:

Age-appropriate immunizations	EKG	Drawing blood
Tympanometry/audiometry screening	X-rays	Minor surgery
Pulmonary function studies	Flexible sigmoidoscopy	Laceration repair
Office gynecology (routine pelvic/PAP)	Asthma treatment	Allergy skin testing
Osteopathic /Chiropractic manipulation	IV hydration/treatment	Physical Therapy

List any special skills or qualifications you or your office staff have that enhance your ability to practice medicine or treat certain patients or classes of patients. List separately any special language skills, such as fluency in a foreign language or proficiency in sign language.

Special Skills of Practitioner:

Special Skills of Staff:

Languages Spoken by Practitioner:

Languages Written by Practitioner:

Languages Spoken by Staff:

Languages Written by Staff:

Is this practice site handicapped accessible (check all that apply)?

		Building	Parking	Wheelchair	Restroom
Does this site employ paraprofessionals for direct patient care?					Yes	No
	If yes, is supervision always provided on premises during paraprofessionals’ direct patient care?
		Yes	No
		Do the paraprofessional(s) bill under any of your Tax ID Numbers?				Yes	No

	If yes, list Tax ID Numbers used:			CONFIDENTIAL INFORMATION

Health Care Professionals Credentialing & Business Data Gathering Form	23
Applicant Name:

Lab Service at this site?	Yes	No
	If yes, check whether:		Primary
CLIA Waiver:	Yes	No

If yes, CLIA Expiration Date:

Secondary

Tertiary

Please provide the following information about physician(s)/practitioner(s) who provide coverage for patients enrolled at this site when you are not available.

Name:

Last

First

Degree

Specialty:

Address:

Telephone: (

)

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID #:

Name:

Last

First

Degree

Specialty:

Address:

Telephone: (

)

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID #:

Name:

Last

First

Degree

Specialty:

Address:

Telephone: (

)

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID #:

Please provide the following information about physician(s)/practitioner(s) who practice in this office:

Name:				Specialty:
	Last	First	MI
Name:				Specialty:
	Last	First	MI
Name:				Specialty:
	Last	First	MI

Health Care Professionals Credentialing & Business Data Gathering Form	24
Applicant Name:

SECTION L. PRIMARY SITE TAX INFORMATION

Please provide the following information for your Primary Site. Include tax information for each business arrangement you use at this site. (Please include additional sheets if more than four applicable business arrangements.)

Business Arrangement #1

Name of Business Arrangement On SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site: ( )

Business Arrangement #2

Name of Business Arrangement On SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site: ( )

Business Arrangement #3

Name of Business Arrangement On SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site: ( )

Business Arrangement #4

Name of Business Arrangement On SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site: ( )

Health Care Professionals Credentialing & Business Data Gathering Form	25
Applicant Name:

SECTION M. ADDITIONAL SITE INFORMATION

Please provide the following information for each additional site at which you practice.

Site

Group/Business Name

Building Name

Office Address – Number and Street – Suite

City					County		State	Zip
(	)
Main Telephone Number			Office Administrator – Last				First	MI
(	)	(		)
Beeper Number			FAX Number			E-mail
(	)	(		)
Emergency Number			Answering Service

Specialty practiced at this site:

Is your practice restricted within your specialty (e.g., by age or type of patient)? If yes, describe the restrictions:

Yes

Briefly describe your practice at this location, including any special practice focus or equipment:

Are you currently accepting new patients at this location?	Yes	No
If yes, describe any restrictions (e.g., appointment type, patient type):

Please provide the number of active patients enrolled with you at this site:

Please provide the number of patient visits you have at this site per year:

Indicate your office schedule at this location in the following table. Write your specific hours in the appropriate spaces for each day:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday

Hours
	to	to	to	to	to	to	to

Health Care Professionals Credentialing & Business Data Gathering Form	26
Applicant Name:

Please indicate standard patient waiting times to schedule an appointment at this site for:

New Patient Existing Patient

Emergency Care

Urgent Care

Symptomatic Care (e.g., sore throat)

Routine Visits (e.g., blood pressure check)

Preventive Routine Care (e.g., school or annual physical)

Please provide the following regarding your practice at this site:

Maximum Number of Appointments per Hour

Average Waiting Time in Office (from scheduled appointment time to actual examination)

Average Response Time for Returning Acute or Urgent Situation:

Patient Calls:

Emergency Situation:

Routine Call:

Please check all procedures you perform at this site:

Age-appropriate immunizations	EKG	Drawing blood
Tympanometry/audiometry screening	X-rays	Minor surgery
Pulmonary function studies	Flexible sigmoidoscopy	Laceration repair
Office gynecology (routine pelvic/PAP)	Asthma treatment	Allergy skin testing
Osteopathic /Chiropractic manipulation	IV hydration/treatment	Physical Therapy

Special Skills of Practitioner:

Special Skills of Staff:

Languages Spoken by Practitioner:

Languages Written by Practitioner:

Languages Spoken by Staff:

Languages Written by Staff:

Is this practice site handicapped accessible (check all that apply)?

		Building	Parking	Wheelchair	Restroom
Does this site employ paraprofessionals for direct patient care?					Yes	No
	If yes, is supervision always provided on premises during paraprofessionals’ direct patient care?
		Yes	No
		Do the paraprofessional(s) bill under any of your Tax ID Numbers?				Yes	No

	If yes, list Tax ID Numbers used:			CONFIDENTIAL INFORMATION

Health Care Professionals Credentialing & Business Data Gathering Form	27
Applicant Name:

Lab Service at this site?	Yes	No
	If yes, check whether:		Primary
CLIA Waiver:	Yes	No

If yes, CLIA Expiration Date:

Secondary

Tertiary

Please provide the following information about physician(s)/practitioner(s) who provide coverage for patients enrolled at this site when you are not available.

Name:

Last

First

Degree

Specialty:

Address:

Telephone: (

)

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID #:

Name:

Last

First

Degree

Specialty:

Address:

Telephone: (

)

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID #:

Name:

Last

First

Degree

Specialty:

Address:

Telephone: (

)

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID #:

Please provide the following information about physician(s)/practitioner(s) who practice in this office:

Name:				Specialty:
	Last	First	MI
Name:				Specialty:
	Last	First	MI
Name:				Specialty:
	Last	First	MI

Health Care Professionals Credentialing & Business Data Gathering Form	28
Applicant Name:

SECTION N. ADDITIONAL SITE TAX INFORMATION

Please provide the following information for each additional site at which you practice. Include tax information for each business arrangement you use at this site. (If there is more than one additional site, or more than five business arrangements at any one site, please copy and complete this page for each additional site and business arrangement.)

Business Arrangement #1

Name of Business Arrangement On SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site: ( )

Business Arrangement #2

Name of Business Arrangement On SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site: ( )

Business Arrangement #3

Name of Business Arrangement On SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site: ( )

Business Arrangement #4

Name of Business Arrangement On SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION: Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site: ( )

End Credentialing and Business Data Gathering Form.

Attach Forms A-F As Required.

Health Care Professionals Credentialing & Business Data Gathering Form	29
Applicant Name:

FORM A – ADVERSE AND OTHER ACTIONS

DUPLICATE this form as necessary to complete separate sheet for EACH occurrence that applies. Use reverse side of this form if additional space is needed.

Applicant Name:

Last

First

Indicate the number of ONE of the questions in Section J to which you answered “yes”: Question Number:

A. Describe the circumstances surrounding this occurrence. Please include the date of the occurrence.

B. Provide an explanation of any actions taken. Please include the date the action was taken.

C. Provide the current status of the issue.

D. If known:

Contact:

Department/Committee:

Address:

Street

City

State

Zip

Telephone: (

)

Signature:

Date:

Health Care Professionals Credentialing & Business Data Gathering Form	FORM A
Applicant Name:

FORM B – PROFESSIONAL LIABILITY ACTIONS

DUPLICATE this form as necessary to complete a separate sheet for EACH action or allegation. Use reverse side of this form if additional space is needed.

Applicant Name:

Last

First

A. Plaintiff’s Name:

Last

First

If court case, Case Name & Case Number:

B.Your Involvement in the Care (Attending, Consulting, Etc.):

C.Your Status in the Case (Sole Defendant, Co-Defendant, Ownership Interest in Provider Practice Name in Suit, Etc.):

D.Allegations, including Patient Outcome, if Available:


E. Date of Incident (mm/yy):		F. Date Filed (mm/yy):

G. Date Case Closed (mm/yy):
Resolution Case:	Dismissed	Judgment	Arbitration	Other
	Settlement out of Court	Pending	Mediation

H.Amount Paid on Your Behalf (if any): $

I.Professional Liability Insurer Name (if one was involved):

J. Insurer Telephone Number: ( )			K. Policy Number:

L. Insurer Address (Street, City, State, Zip Code):

Signature:Date:

Health Care Professionals Credentialing & Business Data Gathering Form	FORM B
Applicant Name:

FORM C – LIABILITY INSURANCE

DUPLICATE this form as necessary to complete a separate sheet for EACH action or allegation. Use reverse side of this form if additional space is needed.

Applicant Name:

Last

First

A.History of Professional Liability Insurance (Please check One)

Canceled Voluntarily			Non-Renewed
Canceled Involuntarily			Application Denied
B. Carrier Name:
C. Carrier Telephone Number: (			)

D.Policy Number:

E.Carrier Address (Street, City, State, Zip Code):

F. Dates of Coverage: From (mm/yy):			To (mm/yy):
G. Circumstances Involved:

Signature:Date:

Health Care Professionals Credentialing & Business Data Gathering Form	FORM C
Applicant Name:

FORM D – CRIMINAL ACTIONS

DUPLICATE this form as necessary to complete a separate sheet for EACH incident. Use reverse side of this form if additional space is needed.

Applicant Name:

Last

First

A.Date of Incident (mm/yy):

B.Date of Complaint or Conviction (mm/yy):

C.Date of Resolution (mm/yy):

D.Type of Resolution (Dismissed, Plea Bargain, Misdemeanor, Felony):

E.Allegation(s):

F.Details of Incident:

G.Actions Taken Against You:

H.Current Status of Situation:

I.Medical Practice Privileges Affected as a Result of This Situation:

Signature:Date:

Health Care Professionals Credentialing & Business Data Gathering Form	FORM D
Applicant Name:

FORM E – MEDICAL CONDITION

DUPLICATE this form as necessary to complete a separate sheet for EACH condition. Use reverse side of this form if additional space is needed.

Applicant Name:

Last

First

A. Describe this medical condition:

B.To what extent does or could this condition affect your current ability to practice medicine in your specialty area or to perform a full range of clinical activities?

C.What is the current status of your condition?

D.Provide the name and address of your personal physician/health care provider who can provide information about your health condition.

	Name			Telephone Number
						(	)
	Last	First	MI	Degree
						(	)
	Last	First	MI	Degree
Signature:					Date:

Health Care Professionals Credentialing & Business Data Gathering Form	FORM E
Applicant Name:

FORM F – CHEMICAL SUBSTANCES OR ALCOHOL ABUSE

DUPLICATE this form as necessary to complete a separate sheet for EACH chemical substance incident. Use reverse side of this form if additional space is needed.

Applicant Name:

Last

First

Describe the substance you use:

A.To what extent does, or could, your use of this substance affect your current ability to practice medicine in your specialty area or to perform a full range of clinical activities?

B. Monitored by State Board Mandate (Name and Address) C. Monitored Voluntarily (Name and Address)

D.Other information about the current status of your use of substances:

E.Abstinent since (mm/yy):

F.Provide the name and address of your personal physician/health care provider who can provide information about your treatment for alcohol or chemical substance use and can comment on what impact (if any) it has on your current/future professional practice.

Name:

Address:

	Street		City		State	Zip
Telephone: (		)
Signature:				Date:

Health Care Professionals Credentialing & Business Data Gathering Form	FORM F
Applicant Name:

Question	Answer
Form Name	Il Credential Form
Form Length	35 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	8 min 45 sec
Other names	illinois state credentialing application, il credential, illinois gateways form, health care professional credentialing and buisiness data gathering form

Policy Limits: Per Occurrence: $

Aggregate: $

Retroactive Date:

(mm/dd/yy)

What type of coverage do you have?

Claims Made

Occurrence