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 C HEALTH CARE PROFESSIONAL UPDATE DATA GATHERING FORM


 

Section 965.APPENDIX C Health Care Professional Update Data Gathering Form

 

STATE OF ILLINOIS

 

Health Care Professional Update 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 the professional. Each hospital, health care entity, and health care plan may also require completion of supplemental forms.

 

INSTRUCTIONS

 

This form is for updating only. Other forms are required for credentialing and for recredentialing.

 

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 recredentialing and internal business purposes.

 

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 will be grounds for rejection or termination, in addition to 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.

 

NOTIFICATION OF CHANGES

 

Provider's Name:

 

 

Last

First

MI

Degree

Date Completed:

 

 

 

(mm/yy)

 

Date of Birth:

 

 

 

(mm/yy)

 

 

Illinois Professional License Number:

 

Social Security Number:

 

 

The following sections of the Health Care Professional Recredentialing and Business Data Gathering Form contain updated information and are attached (check as appropriate).

 

 

ATTACHMENTS

 

Section

A.

General Information

Section

B.

Professional Information

Section

C.

Hospital Membership Current & Pending

Section

D.

Ambulatory Surgical Treatment Center Practice

Section

E.

Work History

Section

F.

Medical Education/Clinical Training Update

Section

G.

Professional History: Confidential

Section

H.

Primary Site Information

Section

I.

Additional Site Information

 

The updated sections are attached and the particular items updated in those sections are highlighted.

 

(Source: Amended at 26 Ill. Reg. 18416, effective December 15, 2002)