Health Care Professional Update Data Gathering Form
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- Bu səhifədəki naviqasiya:
- INSTRUCTIONS
| STATE OF ILLINOIS
Health Care Professional Update Data Gathering FormThe 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.
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.
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.
** 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
Name:
Date Completed:
Date of Birth:
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 Kataloq: about about -> To: The Nominator(s) From about -> 3rd Generation Partnership Project; Technical Specification Group Services and System Aspects about -> Etsi/sage specification Version: 1 Date: 16th March 2009 about -> File Extensions often associated with gis or gps about -> 1. Title and Reporting Relationships about -> 1. Title and Reporting Relationships about -> Enefit contact information about -> 73 Human services (Updated November 2015) about -> 26 Corrections (Updated November 2015) about -> Iiac paper No. 3/2002 information infrastructure advisory committee Yüklə 16.79 Kb. Dostları ilə paylaş:
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