Ill. Admin. Code tit. 77, § 965.APPENDIX A – 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: 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.

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. GENERAL INFORMATION

Name:

Last

First

Degree MD/DO/DC/PhD/MSW/DPM/ DDS/DMD/Other

List other names by which you have been known:

Last

First

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

If "no", do you have a legal right to reside permanently and work in the U.S.?

Yes

CONFIDENTIAL INFORMATION

Resident Visa No:

Medical Education Number:

Emergency Contact Person:

Last

First

Telephone Number:

( )

Mailing Address:

Daytime Phone:

( )

EMAIL Address:

Fax Number:

( )

Check here if you have appended additional information for this Section.

Chapter A

SECTION B. PROFESSIONAL INFORMATION

Illinois Professional License Number:

Unrestricted License?

Yes

If "no", please explain restriction(s)

Current and Previous Professional Licenses in Other States

State:

License #

Exp. Date:

(mm/dd/yy)

Unrestricted License?

Yes

If "no", please explain restriction(s)

State:

License #

Exp. Date:

(mm/dd/yy)

Unrestricted License?

Yes

If "no", please explain restriction(s)

State:

License #

Exp. Date:

(mm/dd/yy)

Unrestricted License?

Yes

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

(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

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if applicable):

(mm/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

Yes

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

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if applicable):

(mm/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

Yes

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

Are you Board Certified in Specialty III?

Yes

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if applicable):

(mm/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

Yes

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

Are you Board Certified in Specialty IV?

Yes

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if applicable):

(mm/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

Yes

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 (last 4 digits):

Original Effective Date:

Expiration Date:

(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

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)

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

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)

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

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)

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

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

Chapter A

SECTION D. 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:

( )

Email:

Degree:

Year Graduated:

Dates attended:

From:

To:

(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

Date Issued:

Serial Number for ECFMG

Were you the subject of any disciplinary action during your time at this

institution?

Yes

(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

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Dates attended:

From:

To:

(mm/yy)

Type of internship:

Rotating

Straight

If straight, please list specialty:

Did you successfully complete this program?

Yes

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

(Attach an explanation of a "yes" answer.)

FIRST RESIDENCY

Institution Name:

Department Chair or Program Director:

Last

First

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Dates attended:

From:

To:

(mm/yy)

Type of residency:

Did you successfully complete this program?

Yes

If "no", please attach an

explanation.

Were you the subject of any disciplinary action during your time at this institution?

Yes

(Attach an explanation of a "yes" answer.)

SECOND RESIDENCY

Institution Name:

Department Chair or Program Director:

Last

First

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Dates attended:

From

To:

(mm/yy)

Type of residency:

Did you successfully complete this program?

Yes

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

(Attach an explanation of a "yes" answer.)

FIRST FELLOWSHIP

Institution Name:

Department Chair or Program Director:

Last

First

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Dates attended:

From:

To:

(mm/yy)

Type of fellowship:

Did you successfully complete this program?

Yes

If "no", please attach an

explanation.

Were you the subject of any disciplinary action during your time at this institution?

Yes

(Attach an explanation of a "yes" answer.)

SECOND FELLOWSHIP

Institution Name:

Department Chair or Program Director:

Last

First

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Dates attended:

From:

To:

(mm/yy)

Type of fellowship:

Did you successfully complete this program?

Yes

If "no", please attach an

explanation.

Were you the subject of any disciplinary action during your time at this institution?

Yes

(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

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Dates:

From:

To:

Rank/Position, if applicable:

(mm/yy)

Were you the subject of any disciplinary action during your time at this institution?

Yes

(Attach an explanation of a "yes" answer.)

TEACHING EXPERIENCE/FACULTY APPOINTMENT (PREVIOUS)

Institution Name:

Department Chair or Program Director:

Last

First

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Dates:

From:

To:

Rank/Position, if applicable:

(mm/yy)

Were you the subject of any disciplinary action during your time at this institution?

Yes

(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. 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.)

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 #:

( )

Any limitations in your area of specialty at this hospital?

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 #:

( )

Any limitations in your area of specialty at this hospital?

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 #:

( )

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.)

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 #:

( )

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 #:

( )

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 #:

( )

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.)

Primary Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

Email:

Telephone #:

( )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

Other Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

Email:

Telephone #:

( )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

Other Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

Email:

Telephone #:

( )

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. 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:

( )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To Present

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

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 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

Name:

Title:

Last

First

Degree

Specialty:

Mailing Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Relationship:

Years Known:

Name:

Title:

Last

First

Degree

Specialty:

Mailing Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

Relationship:

Years Known:

Name:

Title:

Last

First

Degree

Specialty:

Mailing Address:

Street

City

State

Zip

Telephone Number:

( )

Email:

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 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. 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

( )

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

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

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

If "yes", is supervision always provided on premises during paraprofessional's direct patient

care?

Yes

Do the paraprofessionals bill under any of your Tax ID Numbers?

Yes

CONFIDENTIAL INFORMATION: If "yes", list Tax ID Numbers used:

Lab service at this site:

Yes

If "yes", check whether:

Primary

Secondary

Tertiary

CLIA Waiver:

Yes

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

Degree

Specialty:

Address:

Telephone:

( )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

Degree

Specialty:

Address:

Telephone:

( )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

Degree

Specialty:

Address:

Telephone:

( )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

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

Name:

Specialty:

Last

First

Name:

Specialty:

Last

First

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

( )

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

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

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

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

If "yes", is supervision always provided on premises during paraprofessional's direct patient

care?

Yes

Do the paraprofessionals bill under any of your Tax ID Numbers?

Yes

CONFIDENTIAL INFORMATION: If "yes", list Tax ID Numbers used:

Lab service at this site:

Yes

If "yes", check whether:

Primary

Secondary

Tertiary

CLIA Waiver:

Yes

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

Degree

Address:

Telephone:

( )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Specialty:

Last

First

Degree

Address:

Telephone:

( )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Specialty:

Last

First

Degree

Address:

Telephone:

( )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Specialty:

Last

First

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

Name

Specialty:

Last

First

Name

Specialty:

Last

First

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 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

Indicate the number of ONE of the questions in Section J to which you answered "yes":

Question Number:

Describe the circumstances surrounding this occurrence. Please include the date of the occurrence.

Provide an explanation of any actions taken. Please include the date the action was taken.

Provide the current status of the issue.

If known:

Contact:

Department/Committee:

Address:

Street

City

State

Zip

Telephone Number:

( )

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

Plaintiff's Name:

Last

First

If court case, State/jurisdiction, Case Name & Case Number:

Your Involvement in the Care (Attending, Consulting, Etc.):

Your Status in the Case (Sole Defendant, Co-Defendant, Ownership Interest in

Provider Practice Named in Suit, Etc.)

Allegations, including Patient Outcome, If Available:

Date of Incident (mm/yy)

Date Filed (mm/yy)

Date Case Closed (mm/yy):

Case Resolution:

Dismissed

Judgement

Arbitration

Other

Settlement Out of Court

Pending

Mediation

Amount Paid on Your Behalf (if any): $

Professional Liability Insurer Name (if one was involved):

Insurer Telephone Number:

( )

Policy Number (last 4 digits):

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

History of Professional Liability Insurance (Please Check One)

Cancelled Voluntarily

Non-Renewed

Cancelled Involuntarily

Application Denied

Carrier Name:

Carrier Telephone Number:

( )

Policy Number (last 4 digits):

Carrier Address:

Street

City

State

Zip

Dates of Coverage:

From (mm/yy):

To (mm/yy):

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

Date of Incident (mm/yy):

Date of Complaint or Conviction (mm/yy):

Date of Resolution (mm/yy):

Type of Resolution (Dismissed, Plea Bargain, Misdemeanor, Felony):

Allegations:

Details of Incident:

Actions Taken Against You:

Current Status of Situation:

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

Describe this medical condition:

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?

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

Degree

( )

Last

First

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

Describe the substance(s) you use:

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?

Monitored by State Board Mandate (Name and Address)

Monitored Voluntarily (Name and Address)

Other information about the current status of your use of substances:

Abstinent since (mm/yy):

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

Degree

Address:

Street

City

State

Zip

Telephone Number:

( )

Signature (or electronic signature):

Date:

(Source: Amended at 48 Ill. Reg. 12398, effective August 1, 2024)