Section 965.APPENDIX B Health Care Professional
Recredentialing and Business Data Gathering Form
STATE OF ILLINOIS
Health Care
Professional Recredentialing 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 recredential such professional. Each hospital, health care entity,
and health care plan may also require completion of supplemental forms.
INSTRUCTIONS
This form is for recredentialing only. Other forms are
required for credentialing 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 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 Licenses, If
Applicable
Current State Controlled Substance
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.
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Applicant's Signature
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Type or Print Name
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Date
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**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.
CHAPTER A:
PRACTICE AND
PROFESSIONAL INFORMATION
SECTION A. GENERAL
INFORMATION
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Name:
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Last
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First
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MI
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Degree
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List other names by which you have been known:
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Last
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First
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MI
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If you have been known by other names, please explain why
your name changed:
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Birth Date:
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(mm/dd/yy)
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Sex:
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Male
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Female
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U.S. Citizen?
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Yes
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No
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If "no", do you have a legal right to reside
permanently and work in the U.S.?
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Yes
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No
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Resident Visa No:
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CONFIDENTIAL INFORMATION
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Social Security Number:
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Emergency Contact Person:
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Last
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First
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MI
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Telephone Number:
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( )
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Mailing Address:
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Daytime Phone:
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( )
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Fax Number:
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( )
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EMAIL Address:
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Check here if you have appended additional
information for this section.
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CHAPTER A:
SECTION B.
PROFESSIONAL INFORMATION
Illinois Professional License Number:
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License Unlimited?
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Yes
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No
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If "no", please explain limitation
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Current and Previous Professional Licenses in Other
States
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State:
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License #
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Exp. Date:
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(mm/dd/yy)
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License Unlimited?
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Yes
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No
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If "no", please explain limitation
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State:
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License #
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Exp. Date:
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(mm/dd/yy)
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License Unlimited?
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Yes
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No
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If "no", please explain limitation
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State:
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License #
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Exp. Date:
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(mm/dd/yy)
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License Unlimited?
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Yes
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No
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If "no", please explain limitation
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Check here if you have appended
additional information for this section.
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Current Federal DEA License
Number:
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CONFIDENTIAL INFORMATION
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DEA License Number Expiration
Date:
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License Unlimited?
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Yes
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No
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(mm/dd/yy)
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If "no", please explain limitation:
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Check here if you have appended additional information
for this section.
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Current and Previous State Controlled Substance
Numbers:
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CONFIDENTIAL INFORMATION
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State:
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CS License #:
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Expiration Date:
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(mm/dd/yy)
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State:
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CS License #:
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Expiration Date:
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(mm/dd/yy)
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State:
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CS License #:
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Expiration Date:
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(mm/dd/yy)
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Please identify all limitations related to the above
Controlled Substances Numbers and explain limitations
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Medicare Unique Provider ID# (UPIN):
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National Provider Identification Number (NPI):
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Medicaid ID#:
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X-Ray Certification:
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State:
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Certificate #:
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Expiration Date:
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(mm/dd/yy)
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Check here if you have appended additional information
for this section.
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COMPLETE FOR EACH SPECIALTY
Specialty I:
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Are you Board Certified in Specialty I?
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Yes
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No
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If "yes", name of Certifying Board:
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Date of Certification:
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Date of Recertification (if applicable):
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(mm/dd/yy)
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(mm/dd/yy)
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If "no", have you taken or are you scheduled to
take the Specialty Boards Certification?
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Yes
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No
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If Certifying Boards taken, give date:
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(mm/dd/yy)
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Certification Expiration Date, If Any:
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(mm/dd/yy)
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If not taken, date scheduled to take Specialty Boards:
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(mm/dd/yy)
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Specialty/Subspecialty II:
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Are you Board Certified in Specialty II?
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Yes
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No
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If "yes", name of Certifying Board:
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Date of Certification:
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Date of Recertification (if applicable):
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(mm/dd/yy)
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(mm/dd/yy)
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If "no", have you taken or are you scheduled to
take the Specialty Boards Certification?
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Yes
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No
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If Certifying Boards taken, give date:
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(mm/dd/yy)
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Certification Expiration Date, If Any:
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(mm/dd/yy)
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If not taken, date scheduled to take Specialty Boards:
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(mm/dd/yy)
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Specialty/Subspecialty III:
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Are you Board Certified in Specialty III?
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Yes
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No
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If "yes", name of Certifying Board:
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Date of Certification:
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Date of Recertification (if applicable):
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(mm/dd/yy)
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(mm/dd/yy)
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If "no", have you taken or are you scheduled to
take the Specialty Boards Certification?
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Yes
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No
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If Certifying Boards taken, give date:
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(mm/dd/yy)
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Certification Expiration Date, If Any:
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(mm/dd/yy)
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If not taken, date scheduled to take Specialty Boards:
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(mm/dd/yy)
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Specialty/Subspecialty IV:
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Are you Board Certified in Specialty IV?
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Yes
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No
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If "yes", name of Certifying Board:
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Date of Certification:
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Date of Recertification (if applicable):
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(mm/dd/yy)
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(mm/dd/yy)
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If "no", have you taken or are you scheduled to
take the Specialty Boards Certification?
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Yes
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No
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If Certifying Boards taken, give date:
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(mm/dd/yy)
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Certification Expiration Date, If Any:
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(mm/dd/yy)
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If not taken, date scheduled to take Specialty Boards:
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(mm/dd/yy)
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Check here if you have appended additional information
for this section.
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CURRENT
PROFESSIONAL LIABILITY INSURANCE
CONFIDENTIAL INFORMATION:
Carrier:
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Address:
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Street
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City
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State
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Zip
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Policy Number:
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Original Effect Date:
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Expiration Date:
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(mm/dd/yy)
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(mm/dd/yy)
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Policy Limits:
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Per Occurrence:
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$
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Aggregate:
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$
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Retroactive Date:
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(mm/dd/yy)
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What type coverage do you have?
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Claims Made
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Occurrence
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Has any judgement or payment of claim or settlement amount
exceeded the limits of this coverage?
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Yes
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No
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MEMBERSHIP
STATUS – USE FOR SECTIONS C AND D
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Please use the following key to indicate membership
status in sections C
(Hospital Membership – Current and Pending) and D
(Ambulatory Surgical
Treatment Center Practice) below.
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A.
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Active
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F.
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Active Provisional Staff
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K.
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Pending
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B.
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Courtesy
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G.
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Senior Staff
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L.
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Other (Specify)
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C.
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Consulting
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H.
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Associate
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D.
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Adjunct
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I.
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Provisional
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E.
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Suspended/
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J.
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Affiliate
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Terminated/
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Resigned
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SECTION C.
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.
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Primary Hospital
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Hospital Name:
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Address:
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Street
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City
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State
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Zip
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Membership Status (see above):
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Dates:
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To Present
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From (mm/yy)
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Department/Division:
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Medical Staff Office FAX:
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( )
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Department Telephone #:
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( )
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Do you have admitting privileges at this
hospital?
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Yes
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No
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Any limitations in your area of specialty at this
hospital?
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B.
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Other Hospital
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Hospital Name:
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Address:
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Street
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City
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State
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Zip
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Membership Status (see above):
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Dates:
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To Present
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From (mm/yy)
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Department/Division:
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Medical Staff Office FAX:
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( )
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Department Telephone #:
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( )
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Do you have admitting privileges at this hospital?
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Yes
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No
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Any limitations in your area of specialty at this
hospital?
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C.
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Other Hospital
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Hospital Name:
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Address:
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Street
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City
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State
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Zip
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Membership Status (see above):
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Dates:
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To Present
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From (mm/yy)
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Department/Division:
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Medical Staff Office FAX:
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( )
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Department Telephone #:
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( )
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Do you have admitting privileges at this hospital?
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Yes
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No
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Any limitations in your area of specialty at this
hospital?
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Check here if you have appended additional information
for this section
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SECTION D. AMBULATORY SURGICAL TREATMENT CENTER PRACTICE
Please list all ambulatory surgical treatment centers where
you currently have clinical privileges. Use the Membership Status key at the
top of page 7. (Include additional sheets if more than three ASTCs.)
A.
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Primary Ambulatory Surgical
Treatment Center
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ASTC Name:
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Address:
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Street
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City
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State
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Zip
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FAX#:
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( )
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Telephone #:
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( )
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Membership Status (see above):
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Dates:
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From (mm/yy)
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To (mm/yy)
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B.
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Other Ambulatory Surgical Treatment Center
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ASTC Name:
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Address:
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Street
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City
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State
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Zip
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FAX#:
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( )
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Telephone #:
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( )
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Membership Status (see above):
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Dates:
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From (mm/yy)
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To (mm/yy)
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C.
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Other Ambulatory Surgical Treatment Center
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ASTC Name:
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Address:
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Street
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City
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State
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Zip
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FAX#:
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( )
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Telephone #:
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( )
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Membership Status (see above):
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Dates:
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From (mm/yy)
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To (mm/yy)
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Check here if you have appended additional information
for this section.
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SECTION E. 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:
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Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Title or Professional Occupation:
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Time in this employment:
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From:
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To Present
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(mm/yy)
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Previous work place:
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Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Title or Professional Occupation:
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Time in this employment:
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From:
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To:
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(mm/yy)
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(mm/yy)
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Previous work place:
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Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Title or Professional Occupation:
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Time in this employment:
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From:
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To:
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(mm/yy)
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(mm/yy)
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Previous work place:
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Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Title or Professional Occupation:
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Time in this employment:
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From:
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To:
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(mm/yy)
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(mm/yy)
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Previous work place:
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Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Title or Professional Occupation:
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Time in this employment:
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From:
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To:
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(mm/yy)
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Previous work place:
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Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Title or Professional Occupation:
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Time in this employment:
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From:
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To:
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(mm/yy)
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Previous work place:
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Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Title or Professional Occupation:
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Time in this employment:
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From:
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To:
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(mm/yy)
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(mm/yy)
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Previous work place:
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Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Title or Professional Occupation:
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Time in this employment:
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From:
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To:
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(mm/yy)
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(mm/yy)
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Previous work place:
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Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Title or Professional Occupation:
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Time in this employment:
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From:
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To:
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(mm/yy)
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(mm/yy)
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Check here if you have appended additional information
for this section.
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SECTION F. MEDICAL
EDUCATION/CLINICAL TRANING UPDATE
Please provide an update of your medical education and
clinical training over the past four years. Do not duplicate internship,
residency, and fellowship information previously reported. (Attached
additional sheets if necessary.)
FIRST UPDATE
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Fellowship
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Residency
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Other
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Institution Name:
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Department Chair or Program
Director:
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Last Name
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First Name
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MI
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Degree
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Mailing Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Fax Number:
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( )
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Dates attended:
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From:
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To:
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|
|
mm/yy
|
mm/yy
|
|
|
|
Type of internship:
|
Rotating
|
Straight
|
|
If straight, please list
specificaly
|
|
Did you successfully complete
this program?
If no, please list specialty:
|
Yes
|
No
|
|
|
|
Were you the subject of any
disciplinary action during your attendance at this institution?
|
|
(Attached an explanation of a
"Yes" answer.)
|
Yes
|
No
|
|
SECOND UPDATE
|
|
|
Fellowship
|
Residency
|
Other
|
|
Institution Name:
|
|
|
Department Chair and Program
Director:
|
|
|
|
Last Name
|
First Name
|
MI
|
Degree
|
|
Mailing Address:
|
|
|
|
Street
|
City
|
State
|
Zip
|
|
Dates attended:
|
From:
|
|
To:
|
|
|
|
Mm/yy
|
|
Mm/yy
|
|
Types of internship:
|
Rotating
|
Straight:
|
|
If straight, please list specialty:
|
|
|
Did you successfully complete this program?
|
Yes
|
No
|
|
|
|
|
|
Were you the subject of any disciplinary action during
your attendance
|
|
this institution?
|
Yes
|
No
|
|
(Attach an explanation of a "Yes" answer.)
|
|
Check here if you have appended additional information
for this section:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
SECTION G.
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, cancelled 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:
|
|
|
|
|
|
|
|
|
|
|
|
SECTION H. 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
|
|
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:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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:
|
|
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#:
|
|
SECTION I.
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.
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
|
|
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:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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:
|
|
|
|
|
|
|
|
|
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#:
|
|
End Recredentialing
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 I
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:
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Last
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First
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MI
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Describe the substance you use:
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A.
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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?
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B.
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Monitored by State Board Mandate (Name and Address)
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C.
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Monitored Voluntarily (Name and Address)
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D.
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Other information about the current status of your use of
substances:
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E.
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Abstinent since (mm/yy):
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F.
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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.
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Name:
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Last
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First
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MI
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Degree
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Address:
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Street
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City
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State
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Zip
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Telephone Number:
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( )
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Signature:
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Date:
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(Source: Amended at 26 Ill.
Reg. 18416, effective December 15, 2002)