Health Care Professional Update Data Gathering Form - Illinois

This Illinois-specific printable "Health Care Professional Update Data Gathering Form" is a part of the legal paperwork issued by the Illinois Department of Public Health.

Download the up-to-date PDF by clicking the link below and mail it as per the guidelines provided by the department.

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STATE OF ILLINOIS
Health Care Professional Update 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 which 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 updating credentialing only. Other forms are required for credentialing
and for recredentialing.
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.
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 FORM.
**
Health Care Professionals Update Data Gathering Form
1
Applicant Name:
STATE OF ILLINOIS
Health Care Professional Update 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 which 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 updating credentialing only. Other forms are required for credentialing
and for recredentialing.
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.
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 FORM.
**
Health Care Professionals Update Data Gathering Form
1
Applicant Name:
NOTIFICATION OF CHANGES
Name:
Last
First
MI
Degree
Date Completed:
(mm/dd/yy)
Date of Birth:
(mm/dd/yy)
Illinois Professional License Number:
Social Security Number:
The following sections of the Health Care Professional Recredentialing and Business Data Gathering Form
contain updated information and are attached (as appropriate).
ATTACHMENTS:
Section A.
General Information
Section B.
Professional Information
Section C.
Hospital Membership – Current and Pending
Section D.
Ambulatory Surgical Treatment Center Practice
Section E.
Work History
Section F.
Medical Education / Clinical Training Update
Section G.
Professional History: Confidential
Section H.
Primary Site Information
Section I.
Additional Site Information
The updated sections are attached and the particular items updated in those sections are highlighted.
Health Care Professionals Update Data Gathering Form
2
Applicant Name:

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