Ill. Admin. Code tit. 77, 965, Subpart B app A

Current through Register Vol. 48, No. 18, May 3, 2024

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 SignatureType or Print NameDate

**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

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

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

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

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

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

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)	______	______

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:	________

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

-	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Hours:

-	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Hours: