77 Ill. Adm. Code 965.APPENDIX A
A Uniform Health Care and Hospital Credentials Form
Section 965
Section 965.APPENDIX AÂ Â Uniform Health Care and Hospital
Credentials Form
STATE OF ILLINOIS
Uniform Health
Care and Hospital Credentials 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 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 two (2) different
Chapters, each containing various sections:
Chapter A:Â General and Practice
Information
Chapter B:Â Business Information
As previously noted, please consult the specific
credentialing entity instructions for their individual Chapter or section
requirements for submission.
GENERAL INSTRUCTIONS:Â 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.
Any credentials data collected or obtained by the health
care entity, health care plan, or hospital shall be confidential, as provided
by law, and otherwise may not be redisclosed without written consent of the
health care professional, except that in any proceeding to challenge
credentialing or recredentialing, or in any judicial review, the claim of
confidentiality shall not be invoked to deny a health care professional, health
care entity, health care plan, or hospital access to or use of credentials
data. Nothing in this
subsection
prevents a health care entity, health
care plan, or hospital from disclosing any credentials data to its officers,
directors, employees, agents, subcontractors, medical staff members, any
committee of the health care entity, health care plan, or hospital involved in
the credentialing process, or accreditation bodies or licensing agencies.
However, any redisclosure of credentials data contrary to this
subsection
is
prohibited.
(Section 15(h) of the Act)
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 Uniform
Health Care and Hospital Credentials Form.
I understand that this application does not entitle me to
participation in any hospital, health care entity, or health plan.
Applicant's Signature (or
electronic signature)
Type or Print Name
Date
**PLEASE BE ADVISED THAT EACH HOSPITAL, HEALTH CARE
ENTITY, AND HEALTH CARE PLAN MAY ALSO REQUIRE COMPLETION OF AN ATTESTATION AND
RELEASE OF INFORMATION.
Chapter A
PRACTICE
AND PROFESSIONAL INFORMATION
SECTION
A. Â GENERAL INFORMATION
Name:
Last
First
MI
Degree MD/DO/DC/PhD/MSW/DPM/ DDS/DMD/Other
List other names by which you have been known:
Last
First
MI
If you have been known by other names, please explain why
your name changed:
Birth Date:
Place of Birth:
(mm/dd/yy)
City
State
Country
Sex:
Male
Female
Language Fluency of Applicant:
English
Other______
Spanish
U.S. Citizen?
Yes
No
If "no", do you have a legal right to reside
permanently and work in the U.S.?
Yes
No
CONFIDENTIAL INFORMATION
Resident Visa No:
Medical Education Number:
Emergency Contact Person:
Last
First
MI
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Mailing Address:
Daytime Phone:
(Â Â Â Â Â Â Â Â Â )
EMAIL Address:
Fax Number:
(Â Â Â Â Â Â Â Â Â )
Check here if you have appended additional
information for this Section.
Chapter A
SECTION
B. Â PROFESSIONAL INFORMATION
Illinois Professional
License Number:
Unrestricted License?
Yes
No
If "no", please
explain restriction(s)
Current and Previous Professional
Licenses in Other States
State:
License #
Exp. Date:
(mm/dd/yy)
Unrestricted License?
Yes
No
If "no", please
explain restriction(s)
State:
License #
Exp. Date:
(mm/dd/yy)
Unrestricted License?
Yes
No
If "no", please
explain restriction(s)
State:
License #
Exp. Date:
(mm/dd/yy)
Unrestricted License?
Yes
No
If "no", please
explain restriction(s)
Check here if you have
appended additional information for this section.
Current Federal DEA License
Number:
CONFIDENTIAL INFORMATION
DEA License Number Expiration
Date:
Unrestricted License?
Yes
No
(mm/dd/yy)
If "no", please
explain restriction(s):
Check here if you have
appended additional information for this section.
Current and Previous State
Controlled Substance Numbers:
CONFIDENTIAL INFORMATION
State:
CS License #:
Expiration Date:
(mm/dd/yy)
State:
CS License #:
Expiration Date:
(mm/dd/yy)
State:
CS License #:
Expiration Date:
(mm/dd/yy)
Please identify all
limitations related to the above Controlled Substances Numbers and explain
limitations
Medicare Unique Provider ID# (UPIN):
National Provider Identification Number (NPI):
Medicaid ID#:
X-Ray Certification:
State:
Certificate #:
Expiration Date:
(mm/dd/yy)
Check here if you have appended additional information
for this section.
Specialty I:
Are you Board Certified in Specialty I?
Yes
No
If "yes", name of Certifying Board:
Date of Certification:
Date of Recertification (if applicable):
(mm/yy)
(mm/yy)
If "no", have you taken or are you scheduled to
take the Specialty Boards Certification?
Yes
No
If Certifying Boards taken, give date:
(mm/yy)
Certification Expiration Date, If Any:
(mm/yy)
If not taken, date scheduled to take Specialty Boards:
(mm/yy)
Specialty/Subspecialty II:
Are you Board Certified in Specialty/Subspecialty II?
Yes
No
If "yes", name of Certifying Board:
Date of Certification:
Date of Recertification (if applicable):
(mm/yy)
(mm/yy)
If "no", have you taken or are you scheduled to
take the Specialty Boards Certification?
Yes
No
If Certifying Boards taken, give date:
(mm/yy)
Certification Expiration Date, If Any:
(mm/yy)
If not taken, date scheduled to take Specialty Boards:
(mm/yy)
Specialty/Subspecialty III:
Are you Board Certified in Specialty/Subspecialty III?
Yes
No
Are you Board Certified in Specialty III?
Yes
No
If "yes", name of Certifying Board:
Date of Certification:
Date of Recertification (if applicable):
(mm/yy)
(mm/yy)
If "no", have you taken or are you scheduled to
take the Specialty Boards Certification?
Yes
No
If Certifying Boards taken, give date:
(mm/yy)
Certification Expiration Date, If Any:
(mm/yy)
If not taken, date scheduled to take Specialty Boards:
(mm/yy)
Specialty/Subspecialty IV:
Are you Board Certified in Specialty/Subspecialty IV?
Yes
No
Are you Board Certified in Specialty IV?
Yes
No
If "yes", name of Certifying Board:
Date of Certification:
Date of Recertification (if applicable):
(mm/yy)
(mm/yy)
If "no", have you taken or are you scheduled to
take the Specialty Boards Certification?
Yes
No
If Certifying Boards taken, give date:
(mm/yy)
Certification Expiration Date, If Any:
(mm/yy)
If not taken, date scheduled to take Specialty Boards:
(mm/yy)
Check here if you have appended additional information
for this section.
Chapter A
SECTION
C. Â PROFESSIONAL LIABILITY INSURANCE
Please provide information on
all professional liability insurance carriers from whom you have received
coverage in the past 10 years.
CURRENT PROFESSIONAL
LIABILITY INSURANCE
CONFIDENTIAL INFORMATION:
Carrier:
Address:
Street
City
State
Zip
Policy Number (last 4 digits):
Original Effective Date:
Expiration Date:
(mm/dd/yy)
(mm/dd/yy)
Policy Limits:
Per Occurrence:
$
Aggregate:
$
Retroactive Date:
(mm/dd/yy)
What type of coverage do you
have?
Claims Made
Occurrence
Has any judgement or payment of claim or settlement amount
exceeded the limits of this coverage?
Yes
No
PREVIOUS PROFESSIONAL LIABILITY INSURANCE
CONFIDENTIAL INFORMATION:
Carrier:
Address:
Street
City
State
Zip
Policy Number (last 4 digits):
Original Effective Date:
Expiration Date:
(mm/dd/yy)
(mm/dd/yy)
Policy Limits:
Per Occurrence:
$
Aggregate:
$
Retroactive Date:
(mm/dd/yy)
What type of coverage do you have?
Claims Made
Occurrence
Has any judgement or payment of claim or settlement amount
exceeded the limits of this coverage?
Yes
No
PREVIOUS PROFESSIONAL LIABILITY INSURANCE
CONFIDENTIAL INFORMATION:
Carrier:
Address:
Street
City
State
Zip
Policy Number (last 4 digits):
Original Effective Date:
Expiration Date:
(mm/dd/yy)
(mm/dd/yy)
Policy Limits:
Per Occurrence:
$
Aggregate:
$
Retroactive Date:
(mm/dd/yy)
What type of coverage do you have?
Claims Made
Occurrence
Has any judgement or payment of claim or settlement amount
exceeded the limits of this coverage?
Yes
No
PREVIOUS PROFESSIONAL LIABILITY INSURANCE
CONFIDENTIAL INFORMATION:
Carrier:
Address:
Street
City
State
Zip
Policy Number (last 4 digits):
Original Effective Date:
Expiration Date:
(mm/dd/yy)
(mm/dd/yy)
Policy Limits:
Per Occurrence:
$
Aggregate:
$
Retroactive Date:
(mm/dd/yy)
What type of coverage do you have?
Claims Made
Occurrence
Has any judgement or payment of claim or settlement amount
exceeded the limits of this coverage?
Yes
No
Check here if you have appended additional information
for this section.
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
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, had your professional liability
insurance coverage canceled or non-renewed, or had limits reduced?
Yes
No
Chapter A
SECTION
D. Â EDUCATION AND TRAINING
If you have separated from
a clinical training program prior to its conclusion, explain on a separate
sheet of paper and attach to this application.
MEDICAL/PROFESSIONAL
SCHOOL
Institution Name:
Address 1:
Street
City
State
Zip
Address 2:
Region
Country
Telephone Number:
(Â Â Â Â Â Â Â Â )
Email:
Degree:
Year Graduated:
Dates attended:
From:
To:
(mm/yy)
(mm/yy)
If you are a graduate of a foreign medical school, are you
certified by the Educational
Commission for Foreign Medical Graduates (ECFMG)?
Yes
No
Date Issued:
Serial Number for ECFMG
Were you the subject of any disciplinary action during
your time at this
institution?
Yes
No
(Attach an explanation of a "yes" answer.)
If you attended more than one medical/professional school,
please check here and
attach an explanation that duplicates the information
requested above:
INTERNSHIP
Institution Name:
Department Chair or Program Director:
Last
First
MI
Degree
Mailing Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Dates attended:
From:
To:
(mm/yy)
(mm/yy)
Type of internship:
Rotating
Straight
If straight, please list specialty:
Did you successfully complete this program?
Yes
No
If "no", please attach
an explanation.
If more than one internship, please check here and attach
additional information that duplicates
the information requested above:
Were you the subject of any disciplinary action during
your time at this institution?
Yes
No
(Attach an explanation of a "yes" answer.)
FIRST RESIDENCY
Institution Name:
Department Chair or Program Director:
Last
First
MI
Degree
Mailing Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Dates attended:
From:
To:
(mm/yy)
(mm/yy)
Type of residency:
Did you successfully complete this program?
Yes
No
If "no", please attach an
explanation.
Were you the subject of any disciplinary action during
your time at this institution?
Yes
No
(Attach an explanation of a "yes" answer.)
SECOND RESIDENCY
Institution Name:
Department Chair or Program Director:
Last
First
MI
Degree
Mailing Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Dates attended:
From
To:
(mm/yy)
(mm/yy)
Type of residency:
Did you successfully complete this program?
Yes
No
If "no", please attach an
explanation.
If more than two residencies, please check here and attach
additional information that duplicates the information requested above:
Were you the subject of any disciplinary action during
your time at this institution?
Yes
No
(Attach an explanation of a "yes" answer.)
FIRST FELLOWSHIP
Institution Name:
Department Chair or Program Director:
Last
First
MI
Degree
Mailing Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Dates attended:
From:
To:
(mm/yy)
(mm/yy)
Type of fellowship:
Did you successfully complete this program?
Yes
No
If "no", please attach an
explanation.
Were you the subject of any disciplinary action during
your time at this institution?
Yes
No
(Attach an explanation of a "yes" answer.)
SECOND FELLOWSHIP
Institution Name:
Department Chair or Program Director:
Last
First
MI
Degree
Mailing Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Dates attended:
From:
To:
(mm/yy)
(mm/yy)
Type of fellowship:
Did you successfully complete this program?
Yes
No
If "no", please attach an
explanation.
Were you the subject of any disciplinary action during
your time at this institution?
Yes
No
(Attach an explanation of a "yes" answer.)
If more than two fellowships, please check here and attach
additional information that duplicates the information requested above:
TEACHING EXPERIENCE/FACULTY APPOINTMENT (MOST RECENT)
Institution Name:
Department Chair or Program Director:
Last
First
MI
Degree
Mailing Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Dates:
From:
To:
Rank/Position, if applicable:
(mm/yy)
(mm/yy)
Were you the subject of any disciplinary action during
your time at this institution?
Yes
No
(Attach an explanation of a "yes" answer.)
TEACHING EXPERIENCE/FACULTY APPOINTMENT (PREVIOUS)
Institution Name:
Department Chair or Program Director:
Last
First
MI
Degree
Mailing Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Dates:
From:
To:
Rank/Position, if applicable:
(mm/yy)
(mm/yy)
Were you the subject of any disciplinary action during
your time at this institution?
Yes
No
(Attach an explanation of a "yes" answer.)
If more than two teaching experiences/faculty
appointments, check here and attach additional information that duplicates
the information above:
MEMBERSHIP
STATUS – USE FOR SECTIONS E, F AND G
Please use the following key to indicate Membership
Status in Sections E (Hospital Membership – Current and Pending), F (Hospital
Membership – Previous), and G (Ambulatory Surgical Treatment Center Practice)
below:
A.
Active
F.
Active Provisional Staff
K.
Pending
B.
Courtesy
G.
Senior Staff
L.
Other (Specify)
C.
Consulting
H.
Associate
D.
Adjunct
I.
Provisional
E.
Suspended/
J.
Affiliate
Terminated/
Resigned
Chapter A
SECTION E. Â HOSPITAL
MEMBERSHIP – CURRENT AND PENDING
Please list all hospitals at which you are a member of
the Medical Staff and have clinical privileges or have applications for
privileges pending.
(Include additional sheets if more than three
hospitals.)
A.
Primary Hospital
Hospital Name:
Address:
Street
City
State
Zip
Membership Status (see above):
Dates:
To Present
From (mm/yy)
Department/Division:
Medical Staff Office Email:
Department Telephone #:
(Â Â Â Â Â Â Â Â Â )
Any limitations in your area of specialty at this
hospital?
B.
Other Hospital
Hospital Name:
Address:
Street
City
State
Zip
Membership Status (see above):
Dates:
To Present
From (mm/yy)
Department/Division:
Medical Staff Office Email:
Department Telephone #:
(Â Â Â Â Â Â Â Â Â )
Any limitations in your area of specialty at this
hospital?
C.
Other Hospital
Hospital Name:
Address:
Street
City
State
Zip
Membership Status (see above):
Dates:
To Present
From (mm/yy)
Department/Division:
Medical Staff Office Email:
Department Telephone #:
(Â Â Â Â Â Â Â Â Â )
Any limitations in your area of specialty at this
hospital?
Check here if you have appended additional information
for this section
Chapter A
SECTION F. Â HOSPITAL
MEMBERSHIP – PREVIOUS
Please list all hospitals where you previously held
privileges other than during your Internship/Residency/Fellowship. Use the Membership
Status key listed prior to Section E.
(Include additional sheets if more
than three hospitals.)
1.
Hospital Name
Address:
Street
City
State
Zip
Membership Status (see above):
Dates:
From (mm/yy)
To (mm/yy)
Department/Division:
Medical Staff Office Email:
Department Telephone #:
(Â Â Â Â Â Â Â Â Â )
2.
Hospital Name
Address:
Street
City
State
Zip
Membership Status (see above):
Dates:
From (mm/yy)
To (mm/yy)
Department/Division:
Medical Staff Office Email:
Department Telephone #:
(Â Â Â Â Â Â Â Â Â )
3.
Hospital Name
Address:
Street
City
State
Zip
Membership Status (see above):
Dates:
From (mm/yy)
To (mm/yy)
Department/Division:
Medical Staff Office Email:
Department Telephone #:
(Â Â Â Â Â Â Â Â Â )
Check here if you have appended additional information
for this section
Chapter A
SECTION G. Â AMBULATORY
SURGICAL TREATMENT CENTER PRACTICE
Please list all ambulatory surgical treatment centers
where you currently have clinical privileges. Use the Membership Status key
listed prior to Section E.
(Include additional sheets if more than three
ASTCs.)
A.
Primary Ambulatory Surgical
Treatment Center
ASTC Name:
Address:
Street
City
State
Zip
Email:
Telephone #:
(Â Â Â Â Â Â Â Â Â )
Membership Status (see above):
Dates:
From (mm/yy)
To (mm/yy)
B.
Other Ambulatory Surgical Treatment Center
ASTC Name:
Address:
Street
City
State
Zip
Email:
Telephone #:
(Â Â Â Â Â Â Â Â Â )
Membership Status (see above):
Dates:
From (mm/yy)
To (mm/yy)
C.
Other Ambulatory Surgical Treatment Center
ASTC Name:
Address:
Street
City
State
Zip
Email:
Telephone #:
(Â Â Â Â Â Â Â Â Â )
Membership Status (see above):
Dates:
From (mm/yy)
To (mm/yy)
Check here if you have appended additional information
for this section.
Chapter A
SECTION H. Â 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 workplace:
Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Title or Professional Occupation:
Time in this employment:
From:
To Present
(mm/yy)
Previous workplace:
Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Title or Professional Occupation:
Time in this employment:
From:
To:
(mm/yy)
(mm/yy)
Previous workplace:
Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Title or Professional Occupation:
Time in this employment:
From:
To:
(mm/yy)
(mm/yy)
Previous workplace:
Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Title or Professional Occupation:
Time in this employment:
From:
To:
(mm/yy)
(mm/yy)
Previous workplace:
Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Title or Professional Occupation:
Time in this employment:
From:
To:
(mm/yy)
Previous workplace:
Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Title or Professional Occupation:
Time in this employment:
From:
To:
(mm/yy)
Previous workplace:
Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Title or Professional Occupation:
Time in this employment:
From:
To:
(mm/yy)
(mm/yy)
Previous workplace:
Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Title or Professional Occupation:
Time in this employment:
From:
To:
(mm/yy)
(mm/yy)
Previous workplace:
Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Title or Professional Occupation:
Time in this employment:
From:
To:
(mm/yy)
(mm/yy)
Check here if you have appended additional information
for this section.
Chapter A
SECTION I. Â PROFESSIONAL
REFERENCES
Please list the names of three individuals who have
personal knowledge of your current clinical abilities, ethical character, and interpersonal
skills, preferably including at least one person with whom you have worked in
the last 12 months, and who would be willing to provide this information upon request.
If you list partners, relatives, or department chairpersons, please identify their
relationship to you.
CONFIDENTIAL INFORMATION
1.
Name:
Title:
Last
First
MI
Degree
Specialty:
Mailing Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Relationship:
Years Known:
2.
Name:
Title:
Last
First
MI
Degree
Specialty:
Mailing Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Relationship:
Years Known:
3
.
Name:
Title:
Last
First
MI
Degree
Specialty:
Mailing Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Email:
Relationship:
Years Known:
Chapter A
SECTION J. Â PROFESSIONAL
HISTORY:Â 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 ever had your board certification rescinded or
elected not to recertify, and/or failed to recertify?
Yes
No
4.
Have you ever 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 associated
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 your privileges at any hospital or other health care setting
ever been suspended, revoked, voluntarily or involuntarily surrendered,
reduced, restricted, not renewed, denied, or has probation ever been imposed?
Yes
No
8.
Has your membership at any hospital or other health care
setting ever been suspended, revoked, voluntarily or involuntarily
surrendered, not renewed, denied, or has probation even been imposed?
Yes
No
9.
Has your medical staff membership at any hospital or
healthcare institution ever been voluntarily or involuntarily terminated?
Yes
No
10.
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
11.
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
12.
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
13.
Have you ever 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
14.
Has your authority to practice in any state been
suspended, revoked, voluntarily or involuntarily surrendered, been subject to
a consent order or stipulation order, not renewed, denied renewal, or has
probation ever been imposed?
Yes
No
15.
Were you the subject of any disciplinary action(s) during
your attendance at any academic or training institution, either during any
formal education, training, or faculty appointments?
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 ever been charged with or convicted of a felony
or misdemeanor (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 ever 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 currently have a physical illness or mental illness
or disability that results in your inability to practice medicine with
reasonable judgement, skill, and safety? (See Medical Practice Act – 225 ILCS
60/22(a))
Yes
No
CHEMICAL SUBSTANCES OR ALCOHOL USE DISORDER
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.
Do you currently overuse and/or abuse alcohol or any
controlled substances?
Yes
No
2.
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
3.
Are you currently participating in a supervised
rehabilitation program and/or professional assistance program that monitors
you for alcohol and/or substance use disorder?
Yes
No
INVESTMENTS
Apart from employment, in the last 5 years have you and/or
a member of your family ever 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, surgical
center, 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. Â 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
(Â Â Â Â Â Â Â Â Â )
Main Telephone Number
Office Administrator –
Last
First
MI
(Â Â Â Â Â Â Â Â Â )
Fax Number
E-Mail
(Â Â Â Â Â Â Â Â Â )
(Â Â Â Â Â Â Â Â Â )
Emergency Number
Answering Service
Specialty practiced at this site:
Is your practice restricted within your specialty (e.g.,
by age or type of patient)?
Yes
No
If "yes", describe the restrictions:
Briefly describe your practice
at this location, including any special practice focus or
equipment:
Are you currently accepting new
patients at this location?
Yes
No
If "yes", describe any restrictions (e.g.,
appointment type, patient type):
Please provide the number of active patients enrolled with
you at this site:
Please provide the number of patient visits you have at
this site per year:
Please provide the business hours, including days of the
week and hours of operation:
Please indicate standard patient waiting times to
schedule an appointment at this site for:
New Patient
Existing Patient
Emergency
Care
Urgent
Care
Symptomatic
Care (e.g., sore throat)
Routine
Visits (e.g., blood pressure check)
Preventative
Routine Care (e.g., school or annual physical)
Please provide the following regarding your practice at
this site:
Maximum
Number of Appointments per Hour
Average
Waiting Time in Office (from scheduled
appointment time to actual
examination)
Average
Response Time for Returning Patient Calls:
Acute or Urgent Situation:
Emergency Situation:
Routine Call:
Please check all procedures you perform at this site:
Age-appropriate immunizations
EKG
Drawing blood
Tympanometry/audiometry screening
X-rays
Minor surgery
Pulmonary function studies
Flexible sigmoidoscopy
Laceration repair
Office gynecology (routine pelvic/PAP)
Asthma treatment
Allergy
skin testing
Osteopathic/chiropractic manipulation
IV hydration/ treatment
Physical therapy
Acupuncture
Pathology
List any special skills or qualifications you or your
office staff have that enhance your ability to practice medicine or treat
certain patients or classes of patients. List separately any special language
skills, such as fluency in a foreign language or proficiency in sign
language.
Special Skills of Practitioner:
Special Skills of Staff:
Languages Spoken by Practitioner:
Languages Written by Practitioner:
Languages Spoken by Staff:
Languages Written by Staff:
Is this practice site handicapped accessible
(check
all that apply)?
Building
Parking
Wheelchair
Restroom
Does this site employ paraprofessionals for direct
patient care?
Yes
No
If "yes", is supervision always provided on
premises during paraprofessional's direct patient
care?
Yes
No
Do the paraprofessionals bill under any of your Tax ID
Numbers?
Yes
No
CONFIDENTIAL INFORMATION:
If
"yes", list Tax ID Numbers used:
Lab service at this site:
Yes
No
If "yes", check whether:
Primary
Secondary
Tertiary
CLIA Waiver:
Yes
No
CLIA Expiration Date:
Please provide the following information about physicians/practitioners
who provide coverage for patients enrolled at this site when you are not
available.
Name:
Last
First
MI
Degree
Specialty:
Address:
Telephone:
(Â Â Â Â Â Â Â )
Street
City
State
Zip
Availability:
Days
Nights
Weekends
Holidays
CONFIDENTIAL INFORMATION:
Tax ID#:
Name:
Last
First
MI
Degree
Specialty:
Address:
Telephone:
(Â Â Â Â Â Â Â )
Street
City
State
Zip
Availability:
Days
Nights
Weekends
Holidays
CONFIDENTIAL INFORMATION:
Tax ID#:
Name:
Last
First
MI
Degree
Specialty:
Address:
Telephone:
(Â Â Â Â Â Â Â )
Street
City
State
Zip
Availability:
Days
Nights
Weekends
Holidays
CONFIDENTIAL INFORMATION:
Tax ID#:
Name:
Last
First
MI
Degree
Specialty:
Address:
Telephone:
(Â Â Â Â Â Â Â )
Street
City
State
Zip
Availability:
Days
Nights
Weekends
Holidays
CONFIDENTIAL INFORMATION:
Tax ID#:
Please provide the following information about
physicians/practitioners who practice in this office:
Name:
Specialty:
Last
First
MI
Name:
Specialty:
Last
First
MI
Name:
Specialty:
Last
First
MI
Chapter B
SECTION L.Â
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:
(Â Â Â Â Â Â )
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:
(Â Â Â Â Â Â )
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:
(Â Â Â Â Â Â )
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:
(Â Â Â Â Â Â )
Chapter B
SECTION M. Â ADDITIONAL
SITE INFORMATION
Please provide the following information for each
additional site at which you practice. If there is more than one additional
site, copy and complete this section for each additional site.
Site
Group/Business Name
Building Name
Office Address – Number and Street – Suite
City
County
State
Zip
(Â Â Â Â Â Â Â )
Main Telephone Number
Office Administrator –
Last
First
MI
(Â Â Â Â Â Â Â )
Fax Number
E-Mail
(Â Â Â Â Â Â Â )
(Â Â Â Â Â Â Â )
Emergency Number
Answering Service
Specialty practiced at this site:
Is your practice restricted within your specialty (e.g.,
by age or type of patient)?
Yes
No
If "yes", describe the restrictions:
Briefly describe your practice
at this location, including any special practice focus or
equipment:
Are you currently accepting new
patients at this location?
Yes
No
If "yes", describe any restrictions (e.g.,
appointment type, patient type):
Please provide the number of active patients enrolled with
you at this site:
Please provide the number of patient visits you have at
this site per year?
Please provide the business hours, including days of the
week and hours of operation:
Please indicate standard patient waiting times to
schedule an appointment at this site for:
New Patient
Existing Patient
Emergency
Care
Urgent
Care
Symptomatic
Care (e.g., sore throat)
Routine
Visits (e.g., blood pressure check)
Preventative
Routine Care (e.g., school or annual physical)
Please provide the following regarding your practice at
this site:
Maximum
Number of Appointments per Hour
Average
Waiting Time in Office (from scheduled
appointment time to actual
examination)
Average
Response Time for Returning Patient Calls:
Acute or Urgent Situation:
Emergency Situation:
Routine Call:
Please check all procedures you perform at this site:
Age-appropriate immunizations
EKG
Drawing blood
Tympanometry/audiometry screening
X-rays
Minor surgery
Pulmonary function studies
Flexible sigmoidoscopy
Laceration repair
Office gynecology (routine pelvic/PAP)
Asthma treatment
Allergy skin testing
Osteopathic/chiropractic manipulation
IV hydration/ treatment
Physical therapy
Acupuncture
Pathology
List any special skills or qualifications you or your
office staff have that enhance your ability to practice medicine or treat
certain patients or classes of patients. List separately any special language
skills, such as fluency in a foreign language or proficiency in sign
language.
Special Skills of Practitioner:
Special Skills of Staff:
Languages Spoken by Practitioner:
Languages Written by Practitioner:
Languages Spoken by Staff:
Languages Written by Staff:
Is this practice site handicapped accessible
(check
all that apply)?
Building
Parking
Wheelchair
Restroom
Does this site employ paraprofessionals for direct
patient care?
Yes
No
If "yes", is supervision always provided on
premises during paraprofessional's direct patient
care?
Yes
No
Do the paraprofessionals bill under any of your Tax ID
Numbers?
Yes
No
CONFIDENTIAL INFORMATION:
If
"yes", list Tax ID Numbers used:
Lab service at this site:
Yes
No
If "yes", check whether:
Primary
Secondary
Tertiary
CLIA Waiver:
Yes
No
CLIA Expiration Date:
Please provide the following information about physicians/practitioners
who provide coverage for patients enrolled at this site when you are not
available.
Name:
Specialty:
Last
First
MI
Degree
Address:
Telephone:
(Â Â Â Â Â Â Â )
Street
City
State
Zip
Availability:
Days
Nights
Weekends
Holidays
CONFIDENTIAL INFORMATION:
Tax ID#:
Name:
Specialty:
Last
First
MI
Degree
Address:
Telephone:
(Â Â Â Â Â Â Â )
Street
City
State
Zip
Availability:
Days
Nights
Weekends
Holidays
CONFIDENTIAL INFORMATION:
Tax ID#:
Name:
Specialty:
Last
First
MI
Degree
Address:
Telephone:
(Â Â Â Â Â Â Â )
Street
City
State
Zip
Availability:
Days
Nights
Weekends
Holidays
CONFIDENTIAL INFORMATION:
Tax ID#:
Name:
Specialty:
Last
First
MI
Degree
Address:
Telephone:
(Â Â Â Â Â Â Â )
Street
City
State
Zip
Availability:
Days
Nights
Weekends
Holidays
CONFIDENTIAL INFORMATION:
Tax ID#:
Please provide the following information about
physicians/practitioners who practice in this office:
Name
Specialty:
Last
First
MI
Name
Specialty:
Last
First
MI
Name
Specialty:
Last
First
MI
Chapter B
SECTION N.Â
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:
(Â Â Â Â Â Â )
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:
(Â Â Â Â Â Â )
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:
(Â Â Â Â Â Â )
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:
(Â Â Â Â Â Â )
End Uniform Health Care and Hospital Credentials Form.
Attach Forms A-F As Required.
FORM A – ADVERSE
AND OTHER ACTIONS
DUPLICATE this form as necessary to complete separate
sheet for EACH occurrence that applies. Use reverse side of this form if
additional space is needed.
Applicant Name:
Last
First
MI
Indicate the number of ONE of the questions in Section J
to which you answered "yes":
Question Number:
A.
Describe the circumstances surrounding this occurrence.
Please include the date of the occurrence.
B.
Provide an explanation of any actions taken. Please
include the date the action was taken.
C.
Provide the current status of the issue.
D.
If known:
Contact:
Department/Committee:
Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Signature:
Date:
(or electronic signature)
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, State/jurisdiction, 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:
(Â Â Â Â Â Â Â )
K.
Policy Number (last 4 digits):
L.
Insurer Address (Street, City, State, Zip Code):
Signature:
Date:
(or electronic signature)
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:
(Â Â Â Â Â Â Â Â Â )
D.
Policy Number (last 4 digits):
E.
Carrier Address:
Street
City
State
Zip
F.
Dates of Coverage:
From (mm/yy):
To (mm/yy):
G.
Circumstances Involved:
Signature
(or electronic
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
(or electronic
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 this current condition affect your
current ability to practice
medicine in your specialty area or to perform a full range
of clinical activities?
C.
Provide the name and address of your personal
physician/health care provider who can provide information about your health
condition.
Name
Telephone Number
(Â Â Â Â Â Â Â Â Â )
Last
First
MI
Degree
(Â Â Â Â Â Â Â Â Â )
Last
First
MI
Degree
Signature
(or electronic
signature)
:
Date:
FORM F – CHEMICAL
SUBSTANCES OR ALCOHOL USE DISORDER
DUPLICATE this from as necessary to complete a separate
sheet for EACH chemical substance incident. Use reverse side of this form if additional
space is needed.
Applicant Name:
Last
First
MI
Describe the substance(s) you
use:
A.
To what extent does, or could, your use of this (these) substance(s)
affect your current ability to practice medicine in your specialty area or to
perform a full range of clinical activities?
B.
Monitored by State Board Mandate (Name and Address)
C.
Monitored Voluntarily (Name and Address)
D.
Other information about the current status of your use of substances:
E.
Abstinent since (mm/yy):
F.
Provide the name and address of your personal
physician/health care provider who can provide information about your
treatment for alcohol or chemical substance(s) use and can comment on what
impact (if any) it has on your current/future professional practice. Please
attach additional pages if more than one provider needs to be listed.
Name:
Last
First
MI
Degree
Address:
Street
City
State
Zip
Telephone Number:
(Â Â Â Â Â Â Â Â Â )
Signature
(or electronic
signature)
:
Date: