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Illinois Administrative Code (Last Updated: March 27, 2024) |
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TITLE77. PUBLIC HEALTH |
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PART965. HEALTH CARE PROFESSIONAL CREDENTIALS DATA COLLECTION CODE |
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SUBPARTB. ENFORCEMENT ACTION |
§965.APPENDIX A. Health Care Professional Credentialing and Business Data Gathering Form
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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 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. GENERAL INFORMATION
Chapter A
SECTION B. PROFESSIONAL INFORMATION
Illinois Professional License Number:
License Unlimited?
Yes
If "no", please explain limitation
Current and Previous Professional Licenses in Other States
State:
License #
Exp. Date:
(mm/dd/yy)
License Unlimited?
Yes
No
If "no", please explain limitation
State:
License #
Exp. Date:
(mm/dd/yy)
License Unlimited?
Yes
No
If "no", please explain limitation
State:
License #
Exp. Date:
(mm/dd/yy)
License Unlimited?
Yes
No
If "no", please explain limitation
Check here if you have appended additional information for this section.
Current Federal DEA License Number:
CONFIDENTIAL INFORMATION
DEA License Number Expiration Date:
License Unlimited?
Yes
No
(mm/dd/yy)
If "no", please explain limitation:
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. 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:
Original Effective Date:
Expiration Date:
(mm/dd/yy)
(mm/dd/yy)
Policy Limits:
Per Occurrence:
$
Aggregate:
$
Retroactive Date:
(mm/dd/yy)
What type 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:
Original Effective Date:
Expiration Date:
(mm/dd/yy)
(mm/dd/yy)
Policy Limits:
Per Occurrence:
$
Aggregate:
$
Retroactive Date:
(mm/dd/yy)
What type 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:
Original Effective Date:
Expiration Date:
(mm/dd/yy)
(mm/dd/yy)
Policy Limits:
Per Occurrence:
$
Aggregate:
$
Retroactive Date:
(mm/dd/yy)
What type 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:
Original Effective Date:
Expiration Date:
(mm/dd/yy)
(mm/dd/yy)
Policy Limits:
Per Occurrence:
$
Aggregate:
$
Retroactive Date:
(mm/dd/yy)
What type 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.
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
Institution Name:
Mailing Address:
Street
City
State
Zip
Telephone Number:
( )
Fax Number:
( )
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:
( )
Fax Number:
( )
Dates attended:
From:
To:
(mm/yy)
(mm/yy)
Type of internship:
Rotating
Straight
If straight, please list specialty:
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.)
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 FAX #:
( )
Department Telephone #:
( )
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 FAX #:
( )
Department Telephone #:
( )
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 FAX #:
( )
Department Telephone #:
( )
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. 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 FAX #:
( )
Department Telephone #:
( )
2.
Hospital Name
Address:
Street
City
State
Zip
Membership Status (see above):
Dates:
From (mm/yy)
To (mm/yy)
Department/Division:
Medical Staff Office FAX #:
( )
Department Telephone #:
( )
3.
Hospital Name
Address:
Street
City
State
Zip
Membership Status (see above):
Dates:
From (mm/yy)
To (mm/yy)
Department/Division:
Medical Staff Office FAX #:
( )
Department Telephone #:
( )
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.)
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.
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
1.
Name:
Title:
Last
First
MI
Degree
Specialty:
Mailing Address:
Street
City
State
Zip
Telephone Number:
( )
Fax Number:
( )
Relationship:
Years Known:
2.
Name:
Title:
Last
First
MI
Degree
Specialty:
Mailing Address:
Street
City
State
Zip
Telephone Number:
( )
Fax Number:
( )
Relationship:
Years Known:
3.
Name:
Title:
Last
First
MI
Degree
Specialty:
Mailing Address:
Street
City
State
Zip
Telephone Number:
( )
Fax Number:
( )
Relationship:
Years Known:
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.
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
Specialty practiced at this site:
Is your practice restricted within your specialty (e.g., by age or type of patient)?
If "yes", describe the restrictions:
Briefly describe your practice at this location, including any special practice focus or
equipment:
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:
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:
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:
Is this practice site handicapped accessible (check all that apply)?
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:
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:
( )
Street
City
State
Zip
Availability:
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#:
Name:
Last
First
MI
Degree
Specialty:
Address:
Telephone:
( )
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. 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.
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
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?
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
Acupuncture
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:
( )
Street
City
State
Zip
Availability:
Days
Nights
Weekends
Holidays
CONFIDENTIAL INFORMATION: Tax ID#:
Name:
Specialty:
Last
First
MI
Degree
Address:
Telephone:
( )
Street
City
State
Zip
Availability:
Days
Nights
Weekends
Holidays
CONFIDENTIAL INFORMATION: Tax ID#:
Name:
Specialty:
Last
First
MI
Degree
Address:
Telephone:
( )
Street
City
State
Zip
Availability:
Days
Nights
Weekends
Holidays
CONFIDENTIAL INFORMATION: Tax ID#:
Name:
Specialty:
Last
First
MI
Degree
Address:
Telephone:
( )
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. 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 Uniform Health Care and Hospital Credentials
Credentialing and Business Data GatheringForm.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:
( )
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:
Last
First
MI
Describe the substance you use:
A.
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?
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 use and can comment on what impact (if any) it has on your current/future professional practice.
Name:
Last
First
MI
Degree
Address:
Street
City
State
Zip
Telephone Number:
( )
Signature:
Date: