TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER u: MISCELLANEOUS PROGRAMS AND SERVICES
PART 965 HEALTH CARE PROFESSIONAL CREDENTIALS DATA COLLECTION CODE
SECTION 965.APPENDIX A HEALTH CARE PROFESSIONAL CREDENTIALING AND BUSINESS DATA GATHERING FORM


 

Section 965.APPENDIX A   Health Care Professional Credentialing and Business Data Gathering Form

 

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 that 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 REQUIRESTED 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 2 different Chapters, each containing various sections:

 

Chapter A:  General and Practice 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 that 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.


ATTACHMENTS

 

Attach Forms A-F as needed to support "yes" responses in the Professional History section and copies of the following:

 

Curriculum Vitae

 

CONFIDENTIAL INFORMATION:

 

     All Current Professional Licenses

 

     Current Federal DEA License, If Applicable

 

     Current State Controlled Substances Licenses, 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.


Chapter A

 

PRACTICE AND PROFESSIONAL INFORMATION

 

SECTION A. GENERAL INFORMATION

 

 

Name:

 

 

 

Last

First

MI

Degree MD/DO/DC/PhD/MSW/DPM/ DDS/DMD/Other

 

List other names by which you have been known: 

 

 

 

 

Last

First

MI

 

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

 

 

 

Birth Date:

 

Place of Birth:

 

 

 

(mm/dd/yy)

 

City

State

County

 

Sex:

 Male

 Female

Language Fluency of Applicant:

 English

 Other

 

 

 

 

 

 Spanish

 

U.S. Citizen?

 Yes

 No

 

 

 

 

If "no", do you have a legal right to reside permanently and work in the U.S.?

 Yes

 No

 

 

Resident Visa No:

 

 

CONFIDENTIAL INFORMATION

 

 

Social Security Number:

 

 

 

 

Emergency Contact Person:

 

 

 

 

Last

First

MI

 

 

Telephone Number:

(          )

 

 

Mailing Address:

 

Daytime Phone:

(          )

 

 

 

 

EMAIL Address:

 

Fax Number:

(          )

Check here if you have appended additional information for this Section. 


Chapter A

 

SECTION B. PROFESSIONAL INFORMATION

 

Illinois Professional License Number:

License Unlimited?

 Yes

 No

If "no", please explain limitation

 

Current and Previous Professional Licenses 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

 No

 

 

(mm/dd/yy)

 

 

 

If "no", please explain limitation:

 

 

 

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

Current and Previous State Controlled Substance Numbers:

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 limitations related to the above Controlled Substances Numbers and explain limitations

 

 

 

 

 

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.

 

 

Specialty I:

 

 

 

Are you Board Certified in Specialty I?

 Yes

 No

 

 

If "yes", name of Certifying Board:

 

 

 

Date of Certification:

 

Date of Recertification (if  applicable):

 

 

 

 

(mm/yy)

 

(mm/yy)

 

 

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

 

 

 Yes

 No

 

 

If Certifying Boards taken, give date:

 

 

 

 

 

(mm/yy)

 

 

 

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/Subspecialty II?

 Yes

 No

 

 

If "yes", name of Certifying Board:

 

 

 

Date of Certification:

 

Date of Recertification (if  applicable):

 

 

 

 

(mm/yy)

 

(mm/yy)

 

 

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

 

 

 Yes

 No

 

 

If Certifying Boards taken, give date:

 

 

 

 

 

(mm/yy)

 

 

 

Certification Expiration Date, If Any:

 

 

 

 

 

(mm/yy)

 

 

 

If not taken, date scheduled to take Specialty Boards:

 

 

 

 

 

(mm/yy)

 

 

 

 

 

 

 

Specialty/Subspecialty III:

 

 

 

Are you Board Certified in Specialty/Subspecialty III?

 Yes

 No

 

 

Are you Board Certified in Specialty III?

 Yes

 No

 

 

If "yes", name of Certifying Board:

 

 

 

Date of Certification:

 

Date of Recertification (if  applicable):

 

 

 

 

(mm/yy)

 

(mm/yy)

 

 

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

 

 

 Yes

 No

 

 

If Certifying Boards taken, give date:

 

 

 

 

 

(mm/yy)

 

 

 

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/Subspecialty IV?

 Yes

 No

 

 

Are you Board Certified in Specialty IV?

 Yes

 No

 

 

If "yes", name of Certifying Board:

 

 

 

Date of Certification:

 

Date of Recertification (if  applicable):

 

 

 

 

(mm/yy)

 

(mm/yy)

 

 

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

 

 

 Yes

 No

 

 

If Certifying Boards taken, give date:

 

 

 

 

 

(mm/yy)

 

 

 

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.

 


Chapter A

 

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:

 

 

Street

City

State

Zip

Policy Number:

 

Original Effective Date:

 

Expiration Date:

 

 

 

 

(mm/dd/yy)

 

(mm/dd/yy)

Policy Limits:

Per Occurrence:

$

 

Aggregate:

$

 

Retroactive Date:

 

 

 

 

(mm/dd/yy)

 

 

 

What type coverage do you have?

 Claims Made

 Occurrence

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

Yes

No

PREVIOUS PROFESSIONAL LIABILITY INSURANCE

CONFIDENTIAL INFORMATION:

Carrier:

 

Address:

 

 

Street

City

State

Zip

Policy Number:

 

Original Effective Date:

 

Expiration Date:

 

 

 

 

(mm/dd/yy)

 

(mm/dd/yy)

Policy Limits:

Per Occurrence:

$

 

Aggregate:

$

 

Retroactive Date:

 

 

 

 

(mm/dd/yy)

 

 

 

What type coverage do you have?

 Claims Made

 Occurrence

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

Yes

No

 

PREVIOUS PROFESSIONAL LIABILITY INSURANCE

 

CONFIDENTIAL INFORMATION:

Carrier:

 

Address:

 

 

Street

City

State

Zip

Policy Number:

 

Original Effective Date:

 

Expiration Date:

 

 

 

 

(mm/dd/yy)

 

(mm/dd/yy)

Policy Limits:

Per Occurrence:

$

 

Aggregate:

$

 

Retroactive Date:

 

 

 

 

(mm/dd/yy)

 

 

 

What type coverage do you have?

 Claims Made

 Occurrence

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

Yes

No

PREVIOUS PROFESSIONAL LIABILITY INSURANCE

CONFIDENTIAL INFORMATION:

Carrier:

 

Address:

 

 

Street

City

State

Zip

Policy Number:

 

Original Effective Date:

 

Expiration Date:

 

 

 

 

(mm/dd/yy)

 

(mm/dd/yy)

Policy Limits:

Per Occurrence:

$

 

Aggregate:

$

 

Retroactive Date:

 

 

 

 

(mm/dd/yy)

 

 

 

What type coverage do you have?

 Claims Made

 Occurrence

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

Yes

No

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

 


Chapter A

 

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)

 

(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

 

Were you the subject of any disciplinary action during your time 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

First

MI

Degree

Mailing Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Dates attended:

From:

 

To:

 

 

 

(mm/yy)

 

(mm/yy)

 

Type of internship:

Rotating

Straight

If straight, please list specialty:

 

 

 

Did you successfully complete this program?

 Yes

 No

If “no”, please attach

an explanation.

If more than one internship, please check here and attach additional information that duplicates

the information requested above:

 

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

 Yes

 No

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

FIRST RESIDENCY

Institution Name:

 

Department Chair or Program Director:

 

 

Last

First

MI

Degree

Mailing Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Dates attended:

From:

 

To:

 

 

(mm/yy)

 

(mm/yy)

Type of residency:

 

 

Did you successfully complete this program?

 Yes

 No

If “no”, please attach an

explanation.

 

 

 

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

 Yes

 No

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

SECOND RESIDENCY

Institution Name:

 

Department Chair or Program Director:

 

 

Last

First

MI

Degree

Mailing Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

 

Dates attended:

From

 

To:

 

 

(mm/yy)

 

(mm/yy)

Type of residency:

 

 

Did you successfully complete this program?

 Yes

 No

If “no”, please attach an

explanation.

 

 

 

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

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

 Yes

 No

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

FIRST FELLOWSHIP

Institution Name:

 

Department Chair or Program Director:

 

 

Last

First

MI

Degree

Mailing Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Dates attended:

From:

 

To:

 

 

(mm/yy)

 

(mm/yy)

Type of fellowship:

 

 

Did you successfully complete this program?

 Yes

 No

If “no”, please attach an

explanation.

 

 

 

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

 Yes

 No

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

SECOND FELLOWSHIP

Institution Name:

 

Department Chair or Program Director:

 

 

Last

First

MI

Degree

Mailing Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Dates attended:

From:

 

To:

 

 

(mm/yy)

 

(mm/yy)

Type of fellowship:

 

 

Did you successfully complete this program?

 Yes

 No

If “no”, please attach an

explanation.

 

 

 

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

 Yes

 No

(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:

TEACHING EXPERIENCE/FACULTY APPOINTMENT (MOST RECENT)

Institution Name:

 

Department Chair or Program Director:

 

 

Last

First

MI

Degree

Mailing Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Dates:

From:

 

To:

 

Rank/Position, if applicable:

 

 

(mm/yy)

 

(mm/yy)

 

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

 Yes

 No

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

TEACHING EXPERIENCE/FACULTY APPOINTMENT (PREVIOUS)

Institution Name:

 

Department Chair or Program Director:

 

 

Last

First

MI

Degree

Mailing Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Dates:

From:

 

To:

 

Rank/Position, if applicable:

 

 

(mm/yy)

 

(mm/yy)

 

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

 Yes

 No

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

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


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 Surgical Treatment Center Practice) below.

 

A.

Active

F.

Active Provisional Staff

K.

Pending

B.

Courtesy

G.

Senior Staff

L.

Other (Specify)

C.

Consulting

H.

Associate

 

 

D.

Adjunct

I.

Provisional

 

 

E.

Suspended/

J.

Affiliate

 

 

 

Terminated/

 

 

 

 

 

Resigned

 

 

 

 

 


 

Chapter A

 

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:

 

 

Street

City

State

Zip

 

Membership Status (see above):

 

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 (see above):

 

Dates:

 

To Present

 

 

From (mm/yy)

 

 

Department/Division:

 

Medical Staff Office FAX #:

(      )

 

Department Telephone #:

(          )

 

 

Any limitations in your area of specialty at this hospital?

 

 

 

 

 

C.

Other Hospital

 

 

 

Hospital Name:

 

 

Address:

 

 

Street

City

State

Zip

 

Membership Status (see above):

 

Dates:

 

To Present

 

 

From (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

 


 

Chapter A

 

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.)

 

1.

Hospital Name

 

 

Address:

 

 

Street

City

State

Zip

 

Membership Status (see above):

 

Dates:

 

 

 

 

From (mm/yy)

To (mm/yy)

 

Department/Division:

 

Medical Staff Office FAX #:

(      )

 

Department Telephone #:

(          )

 

 

 

 

 

2.

Hospital Name

 

 

Address:

 

 

Street

City

State

Zip

 

Membership Status (see above):

 

Dates:

 

 

 

 

From (mm/yy)

To (mm/yy)

 

Department/Division:

 

Medical Staff Office FAX #:

(      )

 

Department Telephone #:

(          )

 

 

 

 

 

3.

Hospital Name

 

 

Address:

 

 

Street

City

State

Zip

 

Membership Status (see above):

 

Dates:

 

 

 

 

From (mm/yy)

To (mm/yy)

 

Department/Division:

 

Medical Staff Office FAX #:

(      )

 

Department Telephone #:

(          )

 

Check here if you have appended additional information for this section


Chapter A

 

SECTION G. AMBULATORY SURGICAL TREATMENT CENTER PRACTICE

 

Please list all ambulatory surgical treatment centers where you currently have clinical privileges. Use the Membership Status key listed prior to Section E. (Include additional sheets if more than three ASTCs.)

 

A.

Primary Ambulatory Surgical Treatment Center

 

ASTC Name:

 

 

Address:

 

 

Street

City

State

Zip

 

FAX#:

(          )

Telephone #:

(          )

 

Membership Status (see above):

 

Dates:

 

 

 

 

 

From (mm/yy)

 

To (mm/yy)

B.

Other Ambulatory Surgical Treatment Center

 

ASTC Name:

 

 

Address:

 

 

Street

City

State

Zip

 

FAX#:

(          )

Telephone #:

(          )

 

Membership Status (see above):

 

Dates:

 

 

 

 

 

From (mm/yy)

 

To (mm/yy)

C.

Other Ambulatory Surgical Treatment Center

 

ASTC Name:

 

 

Address:

 

 

Street

City

State

Zip

 

FAX#:

(          )

Telephone #:

(          )

 

Membership Status (see above):

 

Dates:

 

 

 

 

 

 

From (mm/yy)

 

To (mm/yy)

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


 

Chapter A

 

SECTION H. WORK HISTORY

 

List chronologically (most recent first) all work engagements (including employment, self-employment, service as an independent contractor, and military service) in the past 4 years. 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 Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

 

Time in this employment:

From:

 

To Present

 

 

(mm/yy)

 

 

Previous work place:

 

Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

 

Time in this employment:

From:

 

To:

 

 

 

(mm/yy)

 

(mm/yy)

 

 

 

 

Previous work place:

 

Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

 

Time in this employment:

From:

 

To:

 

 

 

(mm/yy)

 

(mm/yy)

Previous work place:

 

Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

 

Time in this employment:

From:

 

To:

 

 

 

(mm/yy)

 

(mm/yy)

Previous work place:

 

Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

 

Time in this employment:

From:

 

To:

 

 

 

(mm/yy)

 

Previous work place:

 

Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

 

Time in this employment:

From:

 

To:

 

 

 

 

(mm/yy)

 

Previous work place:

 

Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

 

Time in this employment:

From:

 

To:

 

 

 

(mm/yy)

 

(mm/yy)

Previous work place:

 

Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

 

Time in this employment:

From:

 

To:

 

 

 

(mm/yy)

 

(mm/yy)

Previous work place:

 

Address:

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

 

Time in this employment:

From:

 

To:

 

 

 

(mm/yy)

 

(mm/yy)

 

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

 


Chapter A

 

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

1.

Name:

 

Title:

 

 

Last

First

MI

Degree

 

 

Specialty:

 

 

 

Mailing Address:

 

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Relationship:

 

Years Known:

 

2.

Name:

 

Title:

 

 

Last

First

MI

Degree

 

 

Specialty:

 

 

 

Mailing Address:

 

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Relationship:

 

Years Known:

 

3.

Name:

 

Title:

 

 

Last

First

MI

Degree

 

 

Specialty:

 

 

 

Mailing Address:

 

 

 

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Relationship:

 

Years Known:

 

 


 

Chapter A

 

SECTION J. PROFESSIONAL HISTORY:  CONFIDENTIAL

 

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 questions, please complete FORM A. Please make copies of FORM A as needed and complete one form for each "yes" answer.

 

Adverse or Other Actions

 

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?

Yes

No

2.

Have you ever been reprimanded and/or fined, been the subject of a complaint, and/or 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 that licenses providers?

Yes

No

3.

Have you lost any board certifications, and/or failed to recertify?

Yes

No

4.

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

Yes

No

5.

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

Yes

No

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?

Yes

No

7.

Have you or any of your hospital or ambulatory surgical treatment center (ASTC) privileges and/or membership been denied, revoked, suspended, reduced, placed on probation, proctored, placed under mandatory consultation or non-renewed?

Yes

No

8.

Have you voluntarily or involuntarily relinquished or failed to seek renewal of your hospital or ASTC privileges for any reason?

Yes

No

9.

Have 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 ASTC privileges and/or your license?

Yes

No

10.

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

Yes

No

11.

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

Yes

No

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?

Yes

No

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

No

 

PROFESSIONAL LIABILITY ACTIONS

 

If you answer "yes" to any questions 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 judgements ever been entered against you?

Yes

No

2.

Have any professional liability claim settlements ever been paid by you and/or paid on your behalf?

Yes

No

3.

Are there any currently pending professional liability suits, actions and/or claims filed against you?

Yes

No

4.

Has any person or entity ever been sued for your clinical actions?

Yes

No

 

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 or non-renewed or limits reduced?

Yes

No

 

CRIMINAL ACTIONS

 

If you answer "yes" to any questions 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?

Yes

No

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?

Yes

No

 

MEDICAL CONDITION

 

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

 

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

Yes

No

CHEMICAL SUBSTANCES OR ALCOHOL ABUSE

If you answer "yes" to any questions 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?

Yes

No

2.

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

Yes

No

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?

Yes

No

4.

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

Yes

No

INVESTMENTS

In the last 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?

Yes

No

If "yes", please provide explanation:

 

 

 

 

 


 Chapter B

 

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)?

 

  Yes

  No

If "yes", describe the restrictions:

 

 

 

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:

 

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)

 

 

 

 

 

 

 

 

Preventative 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 Patient Calls:

Acute or Urgent Situation:

 

 

 

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 Practioner:

 

 

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 paraprofessional's direct patient

care?

  Yes

  No

Do the paraprofessionals bill under any of your Tax ID Numbers?

  Yes

  No

 

CONFIDENTIAL INFORMATION:  If "yes", list Tax ID Numbers used:

 

 

 

 

 

 

 

 

Lab service at this site:

  Yes

  No

If "yes", check whether:

 

  Primary

  Secondary

  Tertiary

 

CLIA Waiver:

  Yes

  No

CLIA Expiration Date:

 

Please provide the following information about physicians/practitioners who provide coverage for patients enrolled at this site when you are not available.

Name:

 

 

Last

First

MI

Degree

Specialty:

 

 

Address:

 

Telephone:

(        )

 

Street

City

State

Zip

 

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

 

 

Name:

 

 

Last

First

MI

Degree

Specialty:

 

 

Address:

 

Telephone:

(        )

 

Street

City

State

Zip

 

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

 

 

Name:

 

 

Last

First

MI

Degree

Specialty:

 

Address:

 

Telephone:

(        )

 

Street

City

State

Zip

 

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

 

Name:

 

 

Last

First

MI

Degree

Specialty:

 

Address:

 

Telephone:

(        )

 

Street

City

State

Zip

 

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

 

 

Please provide the following information about physicians/practitioners who practice in this office:

 

Name:

 

Specialty:

 

 

 

 

Last

First

MI

 

 

 

 

Name:

 

Specialty:

 

 

 

 

Last

First

MI

 

 

 

 

Name:

 

Specialty:

 

 

 

 

Last

First

MI

 

 

 

 


Chapter B

 

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:

(       )

 


 

Chapter B

 

SECTION M. ADDITIONAL SITE INFORMATION

 

Please provide the following information for each additional site at which you practice. If there is more than one additional site, copy and complete this section for each additional site.

 

 

 

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)?

 

 

  Yes

  No

If "yes", describe the restrictions:

 

 

 

 

 

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:

 

 

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)

 

 

 

 

 

 

 

 

Preventative 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 Patient Calls:

Acute or Urgent Situation:

 

 

 

 

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

 

 

  Acupuncture

 

 

 

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 paraprofessional's direct patient

 

care?

  Yes

  No

 

Do the paraprofessionals bill under any of your Tax ID Numbers?

  Yes

  No

 

CONFIDENTIAL INFORMATION:  If "yes", list Tax ID Numbers used:

 

 

 

 

 

 

 

 

 

 

Lab service at this site:

  Yes

  No

If "yes", check whether:

 

 

  Primary

  Secondary

  Tertiary

 

 

CLIA Waiver:

  Yes

  No

CLIA Expiration Date:

 

 

Please provide the following information about physicians/practitioners who provide coverage for patients enrolled at this site when you are not available.

Name:

 

Specialty:

 

 

Last

First

MI

Degree

 

Address:

 

Telephone:

(        )

 

Street

City

State

Zip

 

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION:   Tax ID#:

 

 

Name:

 

Specialty:

 

 

Last

First

MI

Degree

 

Address:

 

Telephone:

(        )

 

Street

City

State

Zip

 

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

 

 

Name:

 

Specialty:

 

 

Last

First

MI

Degree

 

Address:

 

Telephone:

(        )

 

Street

City

State

Zip

 

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

 

Name:

 

Specialty:

 

 

Last

First

MI

Degree

 

Address:

 

Telephone:

(        )

 

Street

City

State

Zip

 

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

 

Please provide the following information about physicians/practitioners who practice in this office:

Name

 

Specialty:

 

 

Last

First

MI

 

Name

 

Specialty:

 

 

Last

First

MI

 

Name

 

Specialty:

 

 

Last

First

MI

 

 


Chapter B

 

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 5 business arrangements at any one site, please copy and complete this page for each additional site and business arrangement.)

 

Business Arrangement #1

Site #:

 

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

Site #:

 

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

Site #:

 

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

Site #:

 

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.


 

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

MI

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 Number:

(          )

 

 

 

 

 

Signature:

 

Date:

 

 


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

MI

A.

Plaintiff’s Name:

 

 

 

Last

First

MI

 

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 Named 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):

 

 

 

Case Resolution:

 

Dismissed

Judgement

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:

 

 


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

MI

A.

History of Professional Liability Insurance (Please Check One)

 

Cancelled Voluntarily

Non-Renewed

 

Cancelled Involuntarily

Application Denied

B.

Carrier Name:

 

C.

Carrier Telephone Number:

(          )

D.

Policy Number:

 

 

E.

Carrier Address:

 

 

 

Street

City

State

Zip

F.

Dates of Coverage:

From (mm/yy):

 

To (mm/yy):

 

 

 

 

G.

Circumstances Involved:

 

 

 

Signature:

 

Date:

 

 


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

MI

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.

Allegations:

 

 

 

 

 

 

 

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:

 

 


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

MI

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:

 

 


FORM F – CHEMICAL SUBSTANCES OR ALCOHOL ABUSE

 

DUPLICATE this from 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

MI

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:

 

 

 

Last

First

MI

Degree

 

Address:

 

 

Street

City

State

Zip

 

 

 

Telephone Number:

(          )

 

 

 

Signature:

 

Date: