Health Care Professional Update Data Gathering Form




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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




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: Error: Reference source not found



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 Surgery Center Practice

 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: Error: Reference source not found



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