Ill. Admin. Code tit. 77, pt. 965, subpt. B, app A

Current through Register Vol. 49, No. 2, January 10, 2025

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

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

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/Terminated/Resigned	J.	Affiliate

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

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

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