Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 965 - HEALTH CARE PROFESSIONAL CREDENTIALS DATA COLLECTION CODE › Subpart B - ENFORCEMENT ACTION › Appendix A - Health Care Professional Credentialing and Business Data Gathering Form

Current through Register Vol. 48, No. 28, July 12, 2024
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
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				  image
SECTION B. PROFESSIONAL
				  INFORMATION
Illinois Professional License
				  Number:
License
				  Unlimited?YesNo
If "no", please explain limitation
				  ______________________________________________
Current and Previous Professional Licenses in Other
				  States
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				  image
______________________________________________________________________
Check here if you have appended additional information
				  for this section.
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				  image
Check here if you have appended additional information
				  for this section.
Current and Previous State Controlled Substance
				  Numbers:
CONFIDENTIAL
				  INFORMATION
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				  image
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:
_________________________________________
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Check here if you have appended additional information
				  for this section.
Specialty I:
___________________________________________________
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Specialty/Subspecialty II:
_______________________________________
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Specialty/Subspecialty III:
______________________________________
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Specialty/Subspecialty IV:
______________________________________
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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:
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PREVIOUS PROFESSIONAL LIABILITY INSURANCE
CONFIDENTIAL
				  INFORMATION:
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				  image
PREVIOUS PROFESSIONAL LIABILITY INSURANCE
CONFIDENTIAL
				  INFORMATION:
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				  image
PREVIOUS PROFESSIONAL LIABILITY INSURANCE
CONFIDENTIAL
				  INFORMATION:
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				  image
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
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If you attended more than one medical/professional school,
				  please check here and attach an explanation that duplicates the information
				  requested above:
INTERNSHIP
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FIRST RESIDENCY
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SECOND RESIDENCY
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				  image
FIRST FELLOWSHIP
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SECOND FELLOWSHIP
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				  image
If more than two fellowships, please check here and attach
				  additional information that duplicates the information requested above:
TEACHING EXPERIENCE/FACULTY APPOINTMENT (MOST
				  RECENT)
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				  image
TEACHING EXPERIENCE/FACULTY APPOINTMENT
				  (PREVIOUS)
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				  image
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.)
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				  image
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.)
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				  image
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.)
Click here to view
				  image
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.
Click here to view
				  image
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
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				  image
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.
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				  image
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:
				  ______________________________________________
Click here to view
				  image
Please provide the following information about
				  physicians/practitioners who provide coverage for patients enrolled at this
				  site when you are not available.
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				  image
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.
Click here to view
				  image
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:
				  ______________________________________________
Click here to view
				  image
Please provide the following information about
				  physicians/practitioners who provide coverage for patients enrolled at this
				  site when you are not available.
Click here to view
				  image
Please provide the following information about
				  physicians/practitioners who practice in this office:
Click here to view
				  image
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.
Click here to view
				  image
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.
Click here to view
				  image
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.
Click here to view
				  image
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.
Click here to view
				  image
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.
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				  image
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.
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				  image