1. No category

DEPARTMENT OF
SURGERY
ADVANCED PRACTICE NURSE
RECREDENTIALING MANUAL
Created: 0 6 / 3 0 /2014
Last Updated: 08/06/2014
DEPAR
RTMENT OF
F SURGERY
Y
AD
DVANCED PRACTICE
P
NURSE RE
ECREDENT
TIALING MANUAL
TABLE
E OF CO
ONTENT
TS
Page
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46
Defining
D
the Recredentiali
R
ing Process
The
T Department of Surgery
y Recredentiaaling Checkliist for Advancced Practice N
Nurses
2014
2
APN Ex
xecutive Coun
ncil
2014
2
Advanced Practice Nurse
N
Quarterly Meeting Scchedule
APN
A
Credenttialing and Privileging Com
mmittee Mem
mbers
Medical
M
Stafff Office Checcklist
Application
A
for
f Reappointm
ment
Information
I
Release
R
and Acknowledgem
A
ment Form
Advanced
A
Praactice Nursing
g Written Collaborative A
Agreement
Instructions
I
for
f Delineation of APN Priivileges Rene wal Form
Delineation
D
of
o APN Privileeges Renewal Form
APN
A
Peer Reeview Helpfull Guidelines
APN
A
Peer Reeview Form an
nd Peer Comm
ments
Additional
A
Do
ocumentation
n Required
APN
A
Biograp
phy Informatio
on
Form
F
H-2 – Claim
C
Experieence Verificattion Form (U
UCMC)
State
S
of Illino
ois Health Carre Professionaal Recredentiialing Form
Common
C
Lin
nks used in thee Recredentiaaling Process
Recredentialing Process
The recredentialing process occurs prior to an Advanced Practice Nurse’s two year anniversary or sooner for new
hires. The Medical Staff Office (MSO) Coordinators identify APNs to be recredentialed during the specified cycle
based on the last digit of the APNs’ social security number. The Coordinators notify Surgery HR and the Surgery
Business Administrator of those APNs scheduled for recredentialing and prepares the application packets for
distribution. Departments are provided four to six weeks to complete the packet with their APNs.
The Section Administrator will be notified via email that the MSO recredentialing application has been sent to the
APN directly. The Business Administrator will send the APN an e-mail reminder. The Section Administrator
(and/or their designate) will need to make him/herself available as a resource to the APN for completing the
application prior to the due date. Once the APN has completed the application, he/she should return the packet to
the Section Administrator. The Section Administrator should review the completed packets for any errors before
returning them to the Department of Surgery Business Administrator in O-200.
Once the completed packet is returned to the Business Administrator, he or she will complete a final review, and
if complete, save the application on the MSO Directory and deliver the application to the MSO Credentialing
Coordinator in room B-132 for review to verify the standards, qualifications and documentation for appointment
and/or approval of privileges. The MSO Credentialing Coordinator notifies Surgery HR & the Surgery Business
Administrator if there is any information that is found to be incomplete or inconsistent on an application. The
Business Administrator will notify the Section Administrator of any deficiencies that need to be addressed.
Recredentialing packets that have met all of the standards/qualifications are assigned to a member of the
Advanced Practice Nurse Credential Committee for review and recommendation to the full committee. The Chief
Nursing Officer must sign all APN packets and return them to the MSO Office. The MSO will schedule for the
Practitioner Credentials and Privileges (PCP) Committee. After its evaluation of the application, the PCP
committee will forward the packet to the Medical Executive Committee. The Medical Executive Committee will
conduct any further investigation that it deems appropriate and either recommends to the Board that the applicant
be approved or denied for medical staff privileges. The packet will then be sent to the Board of Trustees for final
approval. Once the renewal is approved the APNs typically will not have to go through this process for another
two years (note: this may vary depending upon SSN or special circumstances).
Recredentialing Packet
The recredentialing packet consists of different forms the APNs must complete. When a Section Administrator
receives the packet it will include the following items:






Medical Staff Office Recredentialing Checklist (p. 9)
Application for Reappointment to the Medical Staff (p. 10)
Information Release and Acknowledgement form (pp. 11-13)
Advanced Practice Nursing Written Collaborative Agreement (pp. 14-17)
Delineation of APN Privileges Renewal Form (p. 19)
APN Peer Review Form and Peer Comments (pp. 21-23)
2
 Form H-2- Claim Experience Verification Form (UCMC) (p. 26)
 Form K- Medicare Attestation Statement (p. 27)
The following items are not included in the initial packet but need to be added to the recredentialing packet by the
Section Administrator:








IDPH State of Illinois form (pp. 28-51)
o IDPH State of Illinois Form (recredentialing)- www.idph.state.il.us/about/credentialing.htm
RN license (Copy)
APN license (Copy)
DEA license (Copy) (if applicable)
State Controlled Substance license (Copy) (if applicable)
ProCred Report
o ProCred Report- http://corecompetency.uchicago.edu. The APN will have to use their CNet ID and
password to login the system.
CME Credit Report
o To obtain a CME Credit Report, please email [email protected]. Please request a CME
transcript for the past and current fiscal year for your APN.
External category 1 CME credit (a minimum of 20 category 1 credits are needed within the last two years)
Please note: It is always preferable that we submit a complete packet to the MSO. However, in certain cases, it
may prove more expeditious to submit an incomplete packet so that the MSO can begin the review. The
following is a list of items that are required in the packet before MSO will begin their review:




Signed Application (p. 9)
Release of Authorization (pp. 11-13)
Form H-2 (p. 26)
Illinois State Form (pp. 28-51)
3
D EPARTMENT OF SURGERY
T
The University off Chicago
55841 S. Marylandd Avenue
R
Room O200 (MC 5030)
C
Chicago, Illinois 660637
P
Phone: 773-702-77508
F
Fax:
773-702-22140
MEDIC
CAL STAFF OFFICE
O
REC
CREDENTIAL
LING CHECK
KLIST – ADV
VANCED PRA
ACTICE NUR
RSE
Name:
Section:
Top portio
on completed by Business
Administrrator
Privilege Expiration
E
Da
ate:
n to Section Administrator:
Date given
Please mak
ke sure all item
ms below are in
ncluded and com
mpleted beforee returning the packet and siggned checklist tto
Amanda O’Connell
O
in O--200.
IMPORT
TANT: When
n making co
orrections on
o forms, DO
O NOT use white out. Please draw
wa
line thro
ough the errror and then
n initial and
d date the co
orrection. D
Do not remo
ove ANY
verification reports that are atttached to th
his packet.
_____ Complete
C
the
e “Application
n for Recred
dentialing” fo
orm. Form n
need to be signed and dated
by applicant and
a collaborrating physic
cian.
_____
Sign and da
ate the “Inforrmation Rele
ease and Accknowledgem
ment Form”.
_____ Complete
C
the
e “Advanced Practice Nu
ursing Writte
en Collabora
ative Agreem
ment”. This iss to
be completed
d by the applicant and co
ollaborating physician. T
The agreeme
ent must be
signed by the
e advanced practice
p
nurs
se and the ccollaborating
g physician.
_____ Complete
C
the
e Claim Expe
erience Veriffication Form
m with signa
ature and datte. If the
advanced pra
actice nurse has been in
nsured for cla
aims by anyy other insura
ance carrierr
other than the
e University of Chicago Medical Cen
nter Self-Insurance Prog
gram, they w
will
need to comp
plete an for each
e
carrier.. A form will be needed ffor any pend
ding claims/ssuits
and recent se
ettlements made
m
during the current 2
2-year MSO
O recredentia
aling period.
_____ Sign
S
and date
e the “Form K – Medicarre Attestatio
on Statementt (UCMC)”.
_____ Complete
C
the
e “Delineation of APN Prrivileges Ren
newal Form””.
_____ In
nclude the “A
APN Peer Re
eview Form”” and “Peer Comments” signed by the APN bein
ng
re
eviewed and
d the APN re
eviewer.
edentialing F
_____ Complete
C
the
e State of Illin
nois Health Care Professsional Recre
Form & Business
Data
D
Gatherin
ng Form and
d attach it with the packe
et. Please no
ote these forms are not
in
ncluded in th
he packet an
nd may be do
ownloaded ffrom this site
e:
http://www.idph.state.il.us
s/about/cred
dentialing.htm
m
_____ Attach
A
the mo
ost recently completed fiscal
f
year an
nd current F
FY ProCred C
Core
Report and make sure sections
Competency
C
s
are
e compliant a
according to guidelines.
4


The system can be accessed through the UCMC intranet site at
http://corecompetency.uchicago.edu by using your CNETID and password.
Contact your section administrator if you need assistance.
Please note: ProCred must be complete per policy in accordance with the date
the PA recredentialing packet is going to Committee, i.e. even though he/she
may be compliant per policy at the time of submission, additional sections may
need to be completed in advance.
_____ Complete the “APN Directory Bio” and submit online or fax to Janet Karol at (773) 8341578.
_____ Attach a copy of RN license.
_____ Attach a copy of APN license.
_____ Attach a copy of current Federal DEA registration (if applicable).
_____ Attach a copy of current Controlled Substance License (if applicable).
_____ Attach a copy of CME Credits.
Date submitted to Business Administrator
Section Administrator
Date
Date
TO BE COMPLETED BY DOS ADMINISTRATION
Reviewed for quality assurance and submitted to MSO
Business Administrator
Total number of delinquencies before privileges approved
Privileges approved
Date
5
Informationa
al Resource that can be referenced d
during
and
a post com
mpletion on the recreden
ntialing packket
2014 APN
A
EXE
ECUTIVE
E COUN
NCIL
Miche
ele Rubin, AP
PN, CNS
APNC
C Chair
mich
hele.rubin@
@uchospitals..edu
Anne Pohlman, APN,
A
CNS
APNC
C Co-Chair
apoh
hlman@med
dicine.bsd.uchicago.edu
u
Kelly Kramer, APN
N, CNP
kkra
[email protected]
go.edu
Annem
marie O’Con
nnor, APN, CNP
C
anne
emarie.ocon
[email protected]
Janet Friant, APN
N, CNP
jane
et.karol@uch
hospitals.edu
u
Ann Nelson,
N
APN, CNP
anellson1@med
dicine.bsd.ucchicago.edu
Nancy
y Spiewak, APN,
A
CRNA
NSp
[email protected]
Judy Holleman,
H
APN,CNP
A
jholl [email protected]
du
Elizab
beth Hood, RN,
R MS, MBA
A,
APN/C
CPNP
ehoo
[email protected]
ago.edu
Linda Bond, APN, CNP
jbond
d@medicine
e.bsd.uchica
ago.edu
Josep
ph Giannini, APN, CNP
jose
eph.giannini@
@uchospitalls.edu
6
To be reta
ained by AP
PN (Informatiional Purposses Only)
2014
Advanced
d Practice Nurse
Quarterly
Q
Meeting
M
Sc
chedule
All arre on a Thu
ursday and
d Mandatory
Date
Location
e
Time
January 16,, 2014
Dora De
D Lee
1
12:00pm-1::00pm
April
A
17, 2014
Dora De
D Lee
1
12:00pm-1::00pm
July 17, 201
14
Dora De
D Lee
1
12:00pm-1::00pm
October
O
16,, 2014
Dora De
D Lee
1
12:00pm-1::00pm
7
To be retained by APN (Informational Purposes Only)
APN Credentialing and Privileging Committee Members
Michele Rubin, APN, CNS
Chair
Ann Nelson
Annemarie O’Connor
Janice Colwell
Mary Ann Francisco
Nada Williamson
Pamela Beauduy
Stefanie Blummer
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
8
MSO Use Only:
__________ Expiration Date
The University of Chicago Medical Center
Medical Staff Office
__________ Received Date
__________ Secondary Reviewer
Advanced Practice Nurse Recredentialing Checklist
Please provide the items below. The packet will be returned if not complete.
Name: ______________________Department _______________ Section ________________
______
Application for Reappointment
______
Information Release and Acknowledgement
______
Collaborative Agreement
______
Delineation of Privileges Form
______
Peer Review Form
______
State of Illinois Health Care Professional Recredentialing & Business Data
Gathering Form
______
Claim Experience Verification Form (H)
______
Form K – Medicare Attestation
______
Copy of RN License
______
Copy of APN License
______
Copy of Controlled Substance License (if applicable)
______
Copy of DEA Registration (if applicable)
______
CME Credits
______
Copy of Certifications
______
Completed ProCred for previous year and current year-to-date showing progress
9
Iff the informatio
on that is pre-populated on thiis form is incorrrect, APN muust update (i.e. - pager
#,, home addresss, etc.). Please draw
d
a line thro
ough any errorrs and then inittial and date.
THE UNIVE
ERSITY OF CHICAGO MEDICAL C
CENTER
5841 Sou
uth Maryland Avenue, Chiccago, Illinois 60637
APP
PLICATION FOR
F
RECRED
DENTIALING
G
N
NAME:
DEPARTME
ENT:
M
MEDICAL CE
ENTER ADDRESS:
Phone #
_________
Mail Code # ___________
________
Fax:_________________________
Pager # _______________
____
__________
E--Mail Addresss:
RESS (if diffferent from ab
bove Medical Center Addrress)
OFFICE ADDR
Street
City
Statee
Z
Zip
Telephone
City
Statee
Z
Zip
Telephone
H
HOME ADDR
RESS:
Street
Answer Yes
or No to
o each
question
n
H
Have any claim
ms alleging negligence
n
beeen filed agaiinst you sinc e your last aappointment??
Y
Yes ____ No _____
_
IF
F YES, Complete Form B
(If “YES”, com
mplete Form B)
B
H
Have you been
n insured forr claims of prrofessional negligence
n
byy any insuran
nce carrier, oother than Th
he
U
University of Chicago
C
Med
dical Center Self-Insuran
nce Program
m, since your llast appointm
ment?
(If “YES”, return with
w applicatiion Form H-22 for each caarrier)
Y
Yes ____ No _____
_
Answer Yes
or No to each
questio
on
IF YES
S, Complete Fo
orm H-2
__
__________
__________
___________
__________
___
A
Applicant’s Sig
gnature
_____
__________
__________
_
Date
APN must
m
sign and date
A
APPROVED: As Collaboraating Physiciaan, I have rev
viewed this prractitioner's quualifications aand clinical aactivities
ovver the past tw
wo years, inclluding his/herr physical and
d mental fitneess, and recom
mmend him/hher for recredeentialing.
ysician Signaturee
Coollaborating Phy
Prrinted Name
Date
Addvance Practice Nurse Credentiaal Committee
Prrinted Name
Date
Chhief Nursing Offficer
Prrinted Name
Date
M
Medical Executivee Committee
Prrinted Name
Date
Collab
borating
Phy
ysician
mus
st sign
and
d date
A
Approved:
Do
ocument signatures for “Collaboratin
“
ng Physician
n” should be consistent w
with the
pri
rimary physic
cian worked with under primary
p
servvice line.
Booard Member, Prrofessional Liability and Practice Subcommitteee
Prrinted Name
Date
Iff this Advancced Practice Nurse
N
is not recommendeed for reapp
pointment, pllease providee a written exxplanation.
10
0
The University of Chicago Medical Center (“UCMC”)
INFORMATION RELEASE AND ACKNOWLEDGMENT
I the undersigned practitioner hereby provide to UCMC the information requested in the Application materials in connection
with my application for clinical privileges and for participation in the various University of Chicago Physician Group health plans,
managed care plans and Medicare and Medicaid programs. I hereby authorize the Medical Staff Office (MSO) to provide the
information to the medical staff and to any organizations for whom the Medical Staff Office performs delegated credentialing,
for their use in evaluating my application to participate with them. I further authorize the MSO to provide the information to
such other persons and entities as the Organizations may require and designate in connection with that evaluation. In
consideration of the MSO making available such information to those Organizations, and of my application being considered and
processed by such Organizations, I specifically submit the information subject to the following terms and conditions and agree
to be legally bound by them.
A.
Representations
I represent that all of the Information provided in or attached as part of this Application is accurate and complete. I
understand and agree that my application will not be processed if it is not complete or if I fail to submit the information or
documents requested. I also understand that any material misrepresentation, misstatement, or omission from my application,
whether intentional or not, may be a basis for denial by the Organization of clinical privileges. In the event that approval of
clinical privileges has been granted prior to the discovery of such misrepresentation, misstatement, or omission, such discovery
may be deemed to constitute automatic relinquishment of my clinical privileges.
B.
Authorizations
(1)
I authorize the UCMC MSO, the Organizations, their medical staffs, and their authorized representatives to consult with
any third party who may have information bearing on my professional qualifications, credentials, clinical competence,
character, ability to perform safely and competently, ethics, behavior, or any other matter reasonably having a
bearing on my qualifications for initial and continued appointment to the medical staff, or to otherwise participate with
the Organizations. This authorization includes the right to inspect or obtain any and all communications, reports,
records, statements, documents, recommendations or disclosures of said third parties that may be relevant to such
questions. In addition, I specifically authorize these third parties to release such information to the MSO, the
Organizations, their medical staffs, and their authorized representatives upon request. This includes release of such
information during the interim between appointment and reappointment for credentialing and peer review purposes,
such as for ongoing professional practice evaluation.
(2)
I authorize the Organizations, their medical staffs, and their authorized representatives to release such information to
other organizations, health care facilities, managed care entities, and their agents, who solicit such information for the
purpose of evaluating my qualifications pursuant to a request for clinical privileges, participating provider status or
other credentialing matter. This includes release of such information for credentialing and peer review purposes, such
as for ongoing professional practice evaluation.
(3)
I authorize the release of information to such parties as I may specifically designate in the future in connection with
my application for participation with additional organizations or entities.
(4)
I authorize UCMC affiliated hospitals and provider entities for which I am an applicant, including the medical staffs and
authorized representatives of the foregoing, to release to one another and share with one another any information
that bears on my professional qualifications, credentials, clinical competence, character, ability to perform safely and
competently, ethics, or professional conduct.
This authorization includes the right to inspect or obtain any
communications, reports, records, statements, documents, recommendations or disclosures bearing on such matters.
C.
Information
(1)
I understand that it is my responsibility to produce adequate information so that my application can be properly
evaluated. In addition to the information provided in this application, I also agree to provide the Organizations with
any additional information which they or their authorized representatives may request. My failure to provide any
requested information will cause my application to be incomplete and will prevent it from being processed.
(2)
I also agree to keep this Information Form current by informing the Organization of any changes in the Information
provided, including, but not limited to, any investigations by a state licensure agency, any change in my professional
liability insurance coverage, the filing of a professional liability lawsuit against me, any change in my status at any
other health care organization, any change in my eligibility for participation in the Medicare or Medicaid programs, and
any change in my ability to safely and competently exercise my clinical privileges because of health status issues,
including impairment.
11
(3)
I will make myself available for interview in regard to my application.
D.
Acknowledgements
I acknowledge that
(1)
Clinical privileges or other forms of participation at the Organization are not a right of every licensed professional who
makes application for the same;
(2)
My request will be evaluated in accordance with prescribed procedures defined by the Organizations and their medical
staff bylaws, rules and regulations;
(3)
All medical staff recommendations relative to my application are subject to the ultimate action of the Organizations’
Boards of Directors, whose decisions shall be final;
(4)
If appointed, my clinical privileges shall be provisional for the time period determined by the Organization’s Board of
Directors;
(5)
I have the responsibility to keep this Information Form current by informing the Organizations, through the Chief
Executive Officer or designee, of any change in the areas of inquiry contained herein, including but not limited to any
change in my professional liability insurance coverage, the filing of a lawsuit against me and any change in my status
at any other organization;
(6)
Continued clinical privileges remain contingent upon my continued demonstration of professional competence and
cooperation, my general support of the Organizations, as evidenced by treatment and continuous care and supervision
of patients for whom I have responsibility and acceptable performance of all responsibilities related thereto as well as
the other factors deemed relevant by the Organizations. Continued clinical privileges shall be granted only on formal
application, according to organization and medical staff bylaws, rules and regulations, and upon final approval of the
Organizations’ Boards of Directors;
E.
Release and Immunity
By applying for clinical privileges, I accept the following conditions and intend to be legally bound by them, regardless of
whether or not I am granted appointment and/or clinical privileges. These conditions shall remain in effect for the duration of
any term of clinical privileges that I may be granted.
(1)
To the fullest extent permitted by law, I extend absolute immunity to, release from any and all liability, and agree not
to sue the Organization, its medical staff, their authorized representatives, and appropriate third parties for any
matter relating to appointment, reappointment, clinical privileges, or my qualifications for the same. This includes any
actions, recommendations, reports, statements, communications, or disclosures involving me, which are made, taken,
or received by the Organization, the medical staff, their authorized representatives, or appropriate third parties.
(2)
I extend absolute immunity to, and release from any and all liability, the Organizations, their authorized
representatives and any third parties, as defined in subsection (3) below, for any acts, communications, reports,
records, statements, documents, recommendations or disclosures involving me, performed, made, requested or
received by the Organizations and their authorized representatives to, from, or by any third party, including otherwise
privileged or confidential information, relating, but not limited to, the following:
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
applications for clinical privileges, including temporary privileges;
periodic reappraisals undertaken for increase or decrease in clinical privileges;
proceedings for suspension or reduction of clinical privileges or for denial or revocation of clinical
privileges or any other disciplinary sanctions;
summary suspensions;
hearing and appellate reviews;
medical care evaluations;
utilization reviews;
any other organization, department, service or committee activities;
matters or inquiries concerning my professional qualifications, credentials, clinical competence, character,
mental or emotional stability, physical condition, ethics or behavior, and
any other matter that might directly or indirectly have an effect on my competence, on patient care or on
the orderly operation of this or any other organization or health care facility.
12
(3)
The term “Organizations and their authorized representatives” means for each of the designated Organizations, the
Organization corporation and any of the following individuals who have any responsibility for obtaining or evaluating
my credentials, or acting upon my application or conduct in the Organization; the members of the Organization’s
Board of Directors and their appointed representatives; the Chief Executive Officer or his designees; other
Organization employees, consultants to the Organization, the Organization’s attorney and his partners, associates or
designees, and all appointees to the medical staff. The term “third parties” means all individuals, including appointees
to the Organization’s medical staff, and appointees to the medical staffs of other organizations or other physicians or
health practitioners, nurses, or other government agencies, organizations, associations, partnerships and corporations,
whether organizations, health care facilities or not, from whom information has been requested by the Organization or
its authorized representatives or who have requested such information from the Organization and its authorized
representatives.
(4)
If, notwithstanding the provisions in this Section F, I institute legal action again the Organization, its medical staff, or
their authorized representatives and do not prevail, I agree to reimburse the Organization, and any medical staff
members, directors, officers, employees and representatives who are named in the action for all costs incurred in
defending such legal action, including reasonable attorney’s fees.
The foregoing shall be privileged to the fullest extent permitted by law. Such privilege shall extend to the Organization and its
authorized representatives, and to any third parties.
_________________________________
Name (print)
____________________
Date
APN must
print name,
sign and date
______________________________
Signature
13
Complete
all
sections
ADVANCED PRACTICE NURSING WRITTEN COLLABORATIVE AGREEMENT
A. ADVANCED PRACTICE NURSE INFORMATION
1.
NAME:
2.
ILLINOIS RN LICENSE NUMBER:
ILLINOIS APN LICENSE NUMBER:
ILLINOIS CONTROLLED SUBSTANCE LICENSE NUMBER:
FEDERAL MID-LEVEL PRACTITIONER DEA NUMBER:
List all certified
specialties if
applicable.
3. AREAS OF CERTIFICATION:
4. CERTIFYING ORGANIZATION:
5. CERTIFICATION EXPIRATION DATE:
6. CERTIFICATION NUMBER:
List
7. PRACTICE SITES:
Medical
Center
8. CONTACT NUMBERS:
information
________________________
FAX NUMBER:
Always
UCMC;
can
include
additional
off-sites
EMERGENCY NUMBERS:
(e.g., pager, answering service)
9. ATTACHMENTS:
Copy of Certification/Recertification
Copies of RN & APN License
Copy of Certificate of Insurance
Copy of Mid-Level Practitioner License
Note attachments
required
B. COLLABORATING PHYSICIAN INFORMATION
Collaborating
MD
Complete all
sections
1.
NAME:
2.
ILLINOIS LICENSE NUMBER:
3.
PRACTICE AREA OR CONCENTRATION:
4.
BOARD CERTIFICATION (if any):
5.
CERTIFYING ORGANIZATION:
6.
PRACTICE SITES:
7.
CONTACT NUMBERS:
________________________
FAX NUMBER:
EMERGENCY NUMBERS:
(e.g., pager, answering service)
------------------------------------------------------------------------------------------------------------------------------14
1.
NAME:
2.
ILLINOIS LICENSE NUMBER:
3.
PRACTICE AREA OR CONCENTRATION:
4.
BOARD CERTIFICATION (if any):
5.
CERTIFYING ORGANIZATION:
6.
PRACTICE SITES:
7.
CONTACT NUMBERS:
________________________
FAX NUMBER:
Do not
complete
additional
collaborati
ng
physician
information
unless
necessary.
This refers
to all other
“consulting
physicians”
in service
line.
EMERGENCY NUMBERS:
(e.g., pager, answering service)
------------------------------------------------------------------------------------------------------------------------------1.
NAME:
2.
ILLINOIS LICENSE NUMBER:
3.
PRACTICE AREA OR CONCENTRATION:
4.
BOARD CERTIFICATION (if any):
5.
CERTIFYING ORGANIZATION:
6.
PRACTICE SITES:
7.
CONTACT NUMBERS:
________________________
FAX NUMBER:
EMERGENCY NUMBERS:
(e.g., pager, answering service)
-------------------------------------------------------------------------------------------------------------------------------
15
C.
ADVANCED PRACTICE NURSE COLLABORATING PHYSICIAN WORKING RELATIONSHIP
1.
SCOPE OF PRACTICE
Under this agreement, the advanced practice nurse will work with the collaborating physician in an active
practice to deliver health care services to
. This includes, but is not
limited to, the diagnosis, treatment and management of acute and chronic health problems; ordering, interpreting
and performing laboratory and radiology tests; prescribing medications, including controlled substances, to the
extent delegated; receiving and dispensing stock and sample medications; performing other therapeutic or
corrective measures as indicated.
Describe
the type
If applicable, the advanced practice nurse shall maintain allied health personnel privileges at the following
of
hospitals for the designated services:
patients
seen
Hospitals:
A copy of this written collaborative agreement shall remain on file at all sites where the advanced practice nurse
renders service and shall be provided to the Illinois Department of Professional Regulation upon request. Any
joint orders or guidelines are set forth or referenced in Attachment B.
Typically
UCMC
2.
MEDICAL DIRECTION
Physician medical direction shall be adequate with respect to collaboration with Certified Nurse Practitioners,
Certified Nurse Midwives, and Certified Clinical Nurse Specialists if a collaborating physician:
(A) participates in the joint formulation and joint approval of orders or guidelines with the advanced
practice nurse and periodically reviews those orders and the services provided patients under those
orders in accordance with accepted standards of medical practice and advanced practice nursing
practice;
(B) is on site at least once a month to provide medical direction and consultation; and
(C) is available through telecommunications for consultation on medical problems, complications, or
emergencies or patient referral. (See 225 ILCS 60/54.5(6).)
The written collaborative agreement shall be for services the collaborating physician generally provided to his or
her patients in the normal course of clinical practice. Medical direction for a Certified Registered Nurse
Anesthetist shall be adequate if:
(A) an anesthesiologist or a physician participates in the joint formulation and joint approval of orders or
guidelines and periodically reviews those orders and the services provided patients under those orders;
and
(B) for anesthesia services, the anesthesiologist or physician participates through discussion of and
agreement with the anesthesia plan and is physically present and available on the premises during the
delivery of anesthesia services for diagnosis, consultation, and treatment of emergency medical
conditions. Anesthesia services in a hospital shall be conducted in accordance with Section 10.7 of the
Hospital Licensing Act and in an ambulatory surgical treatment center in accordance with Section 6.5 of
the Ambulatory Surgical Treatment Center Act. (See 225 ILCS 60/54.5(b-5).)
16
3.
COMMUNICATION, CONSULTATION AND REFERRAL
The advance practice nurse shall consult with the collaborating physician by telecommunication or in person as
needed. In the absence of the designated collaborating physician, another physician shall be available for
consultation.
The advanced practice nurse shall inform each collaborating physician of all written collaborative agreements he
or she has signed with other physicians, and provide a copy of these to any collaborating physician upon
request.
4.
DELEGATION OF PRESCRIPTIVE AUTHORITY
It is intended that this collaboration will include the prescription of medications by the APN, in conjunction with
protocols and guidelines developed between the CP and the APN. The CP will review the prescription of
medications by the APN periodically but at least annually. The APN will obtain a D.E.A. number if this
collaboration includes the prescription of medications. The CP will file with the Department of Professional
Regulation a notice of delegation of prescriptive authority and termination of such delegation, in accordance with
rules to be established by the IDPR. The APN will register with the IDPR as a mid-level practitioner to receive a
controlled substances license in Illinois.
NOTE: ADVANCE PRACTICE NURSE MAY ONLY PRESCRIBE CONTROLLED SUBSTANCES UPON
RECEIPT OF AN ILLINOIS MID LEVEL PRACTITIONER CONTROLLED SUBSTANCE LICENSE.
WE THE UNDERSIGNED AGREE TO THE TERMS AND CONDITIONS OF THIS WRITTEN COLLABORATIVE
AGREEMENT.
Same date for both APN and
APN must sign
and date
Collaborating Physician is
Advanced Practice Nurse
Date
NOT required.
APN must type or
(Advanced Practice Nurse’s Typed or Printed Name)
print name
Collaborating Physician
Date
(Physician’s Typed or Printed Name)
Collaborating Physician
Date
(Physician’s Typed or Printed Name)
Collaborating Physician
Collaborating MD
must sign and
date
Date
Collaborating MD
must type or print
name
(Physician’s Typed or Printed Name)
Collaborating Physician
Date
(Physician’s Typed or Printed Name)
Collaborating Physician
Date
(Physician’s Typed or Printed Name)
Collaborating Physician
Date
(Physician’s Typed or Printed Name)
17
Instructions for Delineation of APN Privileges Renewal Form:
Definitions:
Collaborating Physician – the primary physician with whom the APN is privileges and shares
collaborative practice.
Consulting Physician – other attending physicians working with the APN in practice at UCMC
Board Certification – NP’s and CNS’s AMCC Certification, i.e. ACNP, FNP, PNP, Adult Health CNS
Specialty Certification – Additional certifications, i.e. CCRN, ambulatory care nursing
1.
Complete all form header information. Please copy all certifications for your file.
2.
For every privilege requested, please circle either Renewal = R, Initiate = I, or Terminate = T
request in the 2nd column.
3.
For every privilege requested, please complete the approximate number of times in which
you performed the stated privilege independently in the past year.
4.
For any privilege not requested, please line out, initial, and date next to the privilege.
5.
(Shaded Columns) Complete the shaded columns if you are requesting any new privileges
from the previous approval. For all initial requests for APN privileges (not appearing on your
previous forms, or marked ‘Initial’ request in the 2nd column) Please complete the # of times
the requested privilege was proctored/performed prior to completion of this document.
Depending on your practice specialty, proctoring for privileges may be completed by
collaborating MD, consulting MD, or other APN.
6.
Statement of competency: Please have the collaborating MD initial each privilege in the final
column
7.
APN and Collaborating Physician must both sign and date the bottom of the form.
8.
APN Privileges are completed every 2 years and can be found on the UCMC Website at
http://home.uchospitals.
18
Do not
include a
Consulting
Physician.
1
2
If renewing
privilege, #
of times
cannot
equal zero
3
5
4
6
7
19
APN Peer
P
Rev
view Helpful Gu
uidelines
s
1. Id
dentify a fellow creden
ntialed APN with similar clinical skillss for the Pee
er Review. If you need
assistance in identifying an
a APN for your
y
review, please notiffy one of the
e APNs on th
he APN
Council
C
for as
ssistance or recommend
dations.
2. Case
C
Review
w: Choose a case which is typical fo
or your speciialty and with
hin your sco
ope of care
whether
w
patie
ent care, research, educ
cation, etc. F
For example
e, select a ca
ase from the
e most
frrequent diagnosis seen in
i your practtice or a proj
oject that is tyypical of you
ur practice. Incorporate
evidenced-ba
ased practice
e and focus on outcome
es. Include e
educational materials, use of
protocols, inte
erdisciplinarry involveme
ent, treatmen
nt plans, etc.. relevant to the review. The review
w
should be a comprehens
c
ive discussio
on of your p ractice.
3. Patient
P
Case
e Review: Provide an ov
verview of th
he patient an
nd treatmentt plan. Include
presenting sy
ymptoms, ph
hysical asses
ssment, labss and proced
dures necesssary for diag
gnosing and
d
trreating this in
ndividual. Site
S evidence
e-based stud
dies, UCMC policies and
d protocols, or findings
which
w
were considered in
n coming to a diagnosis and treatme
ent plan.
4. An
A overview of
o treatmentt plan and orr discharge p
planning which addresse
es patient trreatment,
education and
d follow up care.
c
Note all
a referrals, ancillary carre departme
ents you invo
olved in the
ca
are of this pa
atient. Offerr how these intervention
ns addressed
d quality pattient care an
nd
co
ontributed to
o evidence based
b
care. Please do n
not have pa
atient names
s on any records.
EXAMPLES:
E
A. All patients presenting for trea
atment with symptoms o
of depression are assesssed for
suicidality; plan fo
or suicide; ac
ccess to wea
apons and a
ability to contract for safe
ety.
B. Patien
nt presenting
g with acute MI symptom
ms receive a
aspirin at the
e time of arrivval to the
emerg
gency room or upon com
mplaint and a
assessmentt as an inpatient.
C. Pneum
monia patien
nts receive the following
g upon admisssion: a) oxyygenation asssessment;
blood cultures tim
mes three prio
or to antibiottic; initial antibiotic receiived within 6 hours of
hospittalization.
5. Research
R
Prroject, Educ
cational Pro
ogram, Absttract Presen
ntation, etc: Choose a project or
re
esearch topic and demonstrate how your researrch, project or program developed h
has
co
ontributed to
o the educattional develo
opment of nu
urses or patients, improvved the quality of patientt
ca
are, enhanced interdisciiplinary colla
aboration, im
mproved com
mmunication
n among dep
partments,
patients etc. Incorporate written prottocols, resou
urces utilized
d, project im
mplementation, use of
evidenced ba
ased practice
e and the ide
entification o
of results or outcomes achieved. This should be
e
a comprehensive overvie
ew of your prroject with a n evaluation
n of the outco
omes and im
mpact on
quality of care
e.
6. Peer
P
Review
wer commen
nts: APN pe
eer reviewerr comments should asse
ess the APN in the
ca
ategories as
s outlined in the Peer Re
eview. Pleasse be sure to
o address ea
ach category
ry.
Comments
C
should
s
be based
b
on the
e reviewers
s experience
e with the A
APN in theirr area of
clinical and professiona
al practice only.
o
The Sec
ction Adminis
strator is ressponsible forr confirming
all PHI in
nformation is
s excluded b
before submission.
20
0
A
APN must
ccomplete all
in
nformation.
APN
A
Name & Credentials
s: ________
___________
__________
__________
________
T
The reviewerr
should be a
Current
C
Certiffications: __
___________
__________
__________
___________
_______
ccolleague
w
with similar
Position:
P
____
___________
__________
___________
___________
__________
________
skills.
APN
A
Pe
eer Rev
view Form
Reviewer:
R
__
___________
__________
__________
___________
__________
________
Case Review:
R
Choose
C
an
a example typical o
of your prractice, sh
how how yyour
practice
e is evide
enced based, have copies off your doccumentatio
on (i.e. H&
&P,
consultt form, tele
ephone notes, plan
n of care, education
n etc.) tha
at is appro
opriate to
your ca
ase review
w. Please
e attach additional
a
pages ass necessa
ary.
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
Choose a
_______
___________
__________
___________
___________
__________
__________
___________
__________
case
e which is _
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
typiccal
for
_______
___________
__________
___________
___________
__________
__________
___________
__________
yourr specialty _
_______
___________
__________
___________
___________
__________
__________
___________
_
within
and __________
_______
___________
__________
___________
___________
__________
__________
___________
__________
yourr scope of _
_______
___________
__________
___________
___________
__________
__________
___________
care
e__________
whether _
_______
___________
__________
___________
___________
__________
__________
___________
__________
patie
ent care, _
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
rese
earch,
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
educcation,
_______
___________
__________
__________
___________
__________
__________
___________
_
etc. __________
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
_______
___________
__________
___________
___________
__________
__________
___________
__________
_
Tip:
T Include protocols off practice, re
eferences,
guideline
es, etc.
21
APN Reviewer Comments:
All sections must be
completed by the reviewer
Please assess the applicant/APN under the categories listed below. Comments should be based on
experience with the applicant in the professional setting only.
1. Medical/Clinical Knowledge:
Applies APN training, expertise and experience to enhance clinical practice to achieve quality patient
care outcomes. Utilizes best practice principles and evidenced based protocols/guidelines to guide patient
care delivery.
2. Technical and Clinical Skills:
Demonstrates an understanding of the contexts and systems in which healthcare is provided and applies
this knowledge to improve and optimize health care. Utilizes the electronic medical record, clinical tools
and resources to maximize efficiency, accuracy of information and best practice principles in the
delivery of patient care.
3. Clinical Judgment:
Uses evidenced based practice and methods to investigate, evaluate, and improve patient care decision
making and outcomes. Understands scope of practice and appropriately seeks consultation with
collaborating or consulting physicians and other clinical experts as is appropriate.
4. Interpersonal Skills:
Demonstrates interpersonal skills that enable him/her to establish and maintain professional relationships
with patients, families, and other members of health care teams. Works cooperatively and collegially
with others and shares appropriate information and resources to improve patient care outcomes.
22
5. Communication Skills:
Demonstrates communication skills that enable him/her to establish and maintain professional
relationships with patients, families, and other members of health care teams. Demonstrates diplomacy
in dealing with others and respects the diverse backgrounds and opinions of others. Manages conflict in a
productive manner and follows through to resolution.
6. Professionalism:
Demonstrates behaviors that reflect a commitment to continuous professional development, ethical practice,
respect of others, sensitivity to diversity and a responsible attitude towards his/her patients, profession, and
society. Attends professional meetings, participates in ongoing professional education activities and
participates in the education of others i.e. unit based educational seminars, patient care rounds, bedside
consultation and education of nursing staff, speaking engagements at conferences, nursing grand rounds, etc.
APN requesting privileges
must sign
Signature of APN being reviewed: ____________________________________
Signature of APN reviewer: _______________________________________
Date of review: ______/______/______
APN reviewer must sign
Review date must be less than 90
days old.
23
Please com
mplete and atttach the foll owing required docume
ents:
State of Illinois Health
h Care
Professio
onal Recreden
ntialing
and Busin
ness Data Ga
athering
Form
http://w
www.idph.sttate.il.us/abo
out/credentia
aling.htm
ProCred Core
C
Competency
Online Da
atabase Repo
ort
Cards for the most rec
cently
ed fiscal yearr and
complete
current year-to-date.
y
http://p
procred.uchicago.edu
APN Direc
ctory Bio –
Submit on
nline or fax to Janet
Karol at 773-834-1578
7
APN Bio
Inforrmation_distribute
24
4
Submit this form online or fax to Janet Karol at (773) 834-1578.
APN Bio Information
Name (including credentials):
Title:
Department:
Section:
Area of Clinical Focus:
Interested in mentoring graduate school nurses?
Short Bio paragraph:
Highest Nursing Degree Achieved:
Highest Non-Nursing Degree Achieved (if applicable):
Certifications Achieved and Maintained (i.e. ACNP-BC):
Contact Information:
Phone:
Pager:
Fax:
Email:
Department Address:
25
CLAIM EX
XPERIENC
CE VERIFIC
CATION FO
ORM (UCM
MC)
INSTRUC
CTIONS: Complete on
ne form for each
e
carrie r listed in s
section “C” (pgs. 7-8) o
of
the Illinois
s Healthcare
e Professio nal Data Ga
athering Form
UNIV
VERSITY OF
F CHICAGO MEDICAL C
CENTER
MEDICAL STAFF
F OFFICE
RYLAND AVE
ENUE M/C 1
1130, Chicago, Illinois 6
60637
5841 S. MAR
PHO
ONE: (773) 702-3559
7
FA
AX: (773) 83
34-0694
Applicant
A
to
o complete top portion
n only. Retu
urn with application fo
or appointm
ment.
APN should write UCMC
Self Insured
d Trust here.
To:
__
__________
__________
___________
__________
__________
___________
__________
rrier provides
If another ca________
s
Name off Self Insuring Institutio
on, Employ
yer or Insura
ance Carrie
er
coverage as well, APN
should dupliccate this form
and provide________
tthat carrier’s
Address
s: ________
___________
__________
___________
___________
__________
__________
information. For outside
carriers, phone and fax
Phone: __________
_
___________
_
Fax: __
__________
__________
_
numbers, dates insured
and policy nu
umber must
Dates Insured: ____
__________
_______ to __________
_
________ Policy#:___
__________
________
be included.
I was ins
sured by yo
our institutio
on or insura
ance compa
any for the periods listted above. This is to
request that you co
omplete the information
n set forth b
below and s
submit it to
o the Univerrsity of
Chicago
o Medical Sttaff Office, in
i connectio
on with my application
n for privileg
ges.
_______
___________
__________
__________
___________
_______
Signaturre
Date
APN must sign, date, prrint
or type nam
me & SSN
______
__________
________
Socia
al Security #
_______
___________
__________
__________
___________
________
Print or Type Name
e
Do NOT writte below this liine
_______
___________
__________
__________
___________
__________
__________
___________
_________
Have the
ere been any
y medical ma
alpractice cla
aims made o
or cases file
ed against th
he above pra
actitioner, or
settlements made on
n behalf of th
he practitione
er in the passt ten years?
?
_____ YES ___
________
NO ______
If the ans
swer to this
s question is
i yes, pleas
se submit tthe followin
ng on a sepa
arate docum
ment:




o Claim
Date of
Name of Claimant
e/claim pend
ding?
Is case
If case
e is closed: date
d
of closu
ure, disposition and amou
unt, if any, p
paid in settlem
ment or judg
gment
________
___________
____________
___________
___________
____
Signature
e
Date
________
___________
____________
___________
___________
____
Title
Phone
Please fo
orward to University
U
of
o Chicago Medical
M
Cen
nter, Medica
al Staff Office
(This form
m may be du
uplicated as necessary)
26
FORM K – MEDICARE ATTESTATION STATEMENT (UCMC)
INSTRUCTIONS: PLEASE READ CAREFULLY BEFORE SIGNING
PRACTITIONER ATTESTATION CLAUSE
NOTICE TO PRACTITIONER
"Medicare/CHAMPUS/Medicaid payment to the Medical Center is based in part on each patient's
principal and secondary diagnoses and the major procedures performed on the patient, as
attested to by the patient's attending physician by virtue of his or her signature in the medical
record. Anyone who misrepresents, falsifies, or conceals essential information required for
payment of federal funds, may be subject to fine, imprisonment, or civil penalty under applicable
Federal laws."
Please note that you may not “Opt-Out” of Medicare participation in any clinical setting (including
private practice). If you Opt-Out of Medicare you are unable to bill Medicare in all settings for a
minimum of 2 years. Participation in Medicare is a requirement of holding privileges at The
University of Chicago Medical Center.
PRACTITIONER'S ACKNOWLEDGMENT
I acknowledge that I have received the above notice from The University of Chicago Medical
Center.
_______________________________________
Signature
___________________________________
Typed or Printed Name
________________
Date
APN must sign,
date, and print or
type name
27
STATE OF ILLINOIS
Health Care Professional Recredentialing and Business 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 recredentialing only. Other forms are required for credentialing 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:
Chapter B:
Practice and Professional Information
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 which 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.
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.
Health Care Professionals Recredentialing & Business Data Gathering Form
Applicant Name:
28
ATTACHM
MENTS
A
Attach formss A-F as need
ded to supporrt “yes” resp
ponses in Secction G: Proffessional Histtory and cop
pies of the
ffollowing:
Curricu
ulum Vitae
CONFIDENTIAL IN
NFORMATIO
ON:
Alll Current Profeessional Licensses
Cu
urrent Federal DEA
D
License, If
I Applicable
Curren
nt State Controlled Substancee License(s), Iff Applicable
Curren
nt Professionall Liability Insu
urance Face Shheet or Declaraation of Insurannce
with Effective
E
Datee, Expiration Date
D
and Amoount Displayedd per Occurrennce
and In
n Aggregate
Curren
nt CLIA Certifi
ficate, If Appliccable
Curren
nt W-9s, If App
plicable
AFFIRM
MATION OF INFORMATIO
ON
I reprresent and waarrant that all of the inform
mation provid
ded and the reesponses giveen are correct and completee to the best of
o
my kknowledge an
nd belief. I understand th
hat falsificatiion or omissiion of inform
mation may bbe grounds fo
for rejection or
o
termiination, in addition to any penalties pro
ovided by law
w. I further aggree to prompptly inform all entities to w
which this form
m
sent
and
not
was
t rejected of any change required to be updated by the Healtth Care Proffessional Credentialing an
nd
Businness Data Gatthering Updaate Form.
I undderstand that this
t applicatio
on does not en
ntitle me to paarticipation inn any hospitall, health care entity, or heaalth plan.
APNs will need to sign and
a print namee and date (datee must be han
ndwritten, not typed).
s
and older copies oof this form cannnot be accepteed if the
Forms witthout original signatures
form is daated more than 180 days of beeing recredentiialed.
Appllicant’s Signaature
**
**
**
Type oor Print Namee
Date
PLEASE BE
B ADVISED
D THAT EACH HOSPIT
TAL, HEALT
TH CARE EN
NTITY,
AND HEA
ALTH CARE
E PLAN MAY
Y ALSO REQ
QUIRE COMP
PLETION O
OF AN
ATT
TESTATION
N AND RELEA
ASE OF INF
FORMATION
N FORM.
**
***
***
Healthh Care Professio
onals Recredentiaaling & Business Data
29
9
APN must
m complete this
t entire pagee.
CHAPTER
C
R A:
PRACTICE
P
E AND PR
ROFESSIONAL IN
NFORMAT
TION
SECTION
S
A. GENERAL
L INFORMA
ATION
Namee:
Last
First
MI
Degrree
List oother names by
y which you hav
ve been known
n:
First
Last
M
MI
If youu have been kn
nown by other names,
n
please explain
e
why yo
our name changged:
Birth Date:
(mm/dd
d/yy)
Sex: Male
Female
U.S. Citizen
n? Yes
No
If no, do you
u have a legal right to reside permanently
p
annd work in the U
U.S.? Yes
N
No
CONF
FIDENTIAL IN
NFORMATIO
ON
Resiident Visa
No:
Thiss information iss
nnot required.
Sociial Security
Num
mber:
Emeergency Contacct
Person:
Last
First
MI
Telep
phone Numberr: ( )
Mailiing Address:
Sttreet
Daytiime Phone: ( )
City
State
Zip
Fax Numberr: ( )
E-Maail Address:
h
appendeed additional in
nformation fo
or this section::
Checck here if you have
(P
Please continuee next page)
Applican
nt name must either
e
appear on
n the bottom off each page orr be excluded frrom
every page.
30
0
SECTION B.
B PROFESS
SIONAL INF
FORMATIO
ON
A
APN must enteer license numbber
aand indicate iff it is unlimitedd or not.
Illinoois Professionall License Number:
License Un
nlimited?
Yes
Y
No
If No, please
p
explain llimitation:
Currrent Profession
nal License(s) in Other States
S
State:
License #:
Liceense Unlimited
d?
Yes
Exp. Date:
No
If No, please eexplain limitatiion:
License #:
S
State:
d?
Liceense Unlimited
Yes
Exp. Date:
No
Liceense Unlimited
d?
Yes
((mm/dd/yy)
If No, please eexplain limitatiion:
License #:
S
State:
(mm/dd/yy)
Exp. Date:
No
((mm/dd/yy)
If APN
has
licenses in
other
states, they
must enter
the license
number
and
indicate if
license is
unlimited
or not.
If No, please eexplain limitatiion:
M
Must enter DEA
A license numbber,
eexpiration date and indicate iff the
license is unlim
mited or not.
C
Check here if you
y have appeended addition
nal informatio
on for this secttion:
Current Federal DEA License Number:
CONF
NFIDENTIAL IINFORMATIO
ON
D
DEA License Number
N
Expiraation Date:
License Unlim
mited? Yes N
No
If No, pleaase explain limiitation:
C
Check here if you
y have appeended addition
nal informatio
on for this secttion:
Currrent State Con
ntrolled Substa
ance Number((s):
CONFID
DENTIAL INF
FORMATION
N
CS Liceense #:
S
State:
Expiratioon Date:
(mm
m/dd/yy)
S
State:
CS Liceense #:
Expiratioon Date:
S
State:
CS Liceense #:
Expiratioon Date:
(mm
m/dd/yy)
APN must
list the
state
for their
current
controlled
substance
license,
the license
number
and
expiration
date.
(mm
m/dd/yy)
P
Please identiify
liimitation.
all
lim
mitation
rela
ated
to
the
above
C
Controlled
S
Substances
Number(s)
Applicant name mus
st either appea
ar on the bottom
m of each page
e or be exclude
ed from
every page.
and
explain
n
31
APNs musst enter their
NPI numbeer.
P
ID# (UPIN):
(
Mediicare Unique Provider
Natioonal Provider Identification
n Number (NP
PI):
See “Commonn Links” for morre
info regarding NPI.
Mediicaid ID#:
X-Raay Certificatio
on: State:
Certificaate #:
Exp iration Date:
Checck here if you have
h
appendeed additional in
nformation fo
or this section::
mm/dd/yy)
(m
APNs m
may leave “X-R
Ray Certificatioon” blank.
COM
MPLETE FO
OR EACH SPECIALTY
Speciialty I:
oard Certified in Specialty I? Yes
Are you Bo
No
N
If Yes, nam
me of Certifyin
ng Board:
Date of Ceertification:
Date of Recertification
R
(if applicable):
(m
mm/yy)
(mm/yy)
If No, havee you taken or are you schedu
uled to take thee specialty boarrds certificationn? Yes
If Certifyin
ng Boards taken, give date:
No
Certification Expiration Datte, if Any:
(mm/yy)
((mm/yy)
If not taken
n, date schedulled to take Speccialty Boards:
(mm/yy)
Speciialty/Subspeciialty II:
Are you Bo
oard Certified in Specialty II?? Yes
No
N
APNs must
enter areas
of
certification
(i.e.
Pediatric
Nurse
Practitioner
Primary
Care). This
information
can be
found on
the
verification
reports
included in
their
packet.
If Yes, nam
me of Certifyin
ng Board:
Date of Ceertification:
Date of Recertification
R
(if applicable):
(m
mm/yy)
(mm/yy)
If No, havee you taken or are you schedu
uled to take thee specialty boarrds certificationn? Yes
If Certifyin
ng Boards taken, give date:
No
Certification Expiration Datte, if Any:
(mm/yy)
((mm/yy)
If not taken
n, date schedulled to take Speccialty Boards:
(mm/yy)
(P
Please continu
ue next page)
Applican
nt name must either
e
appear on
n the bottom off each page orr be excluded frrom
every page.
32
2
Speciialty/Subspeciialty III:
Are you Bo
oard Certified in Specialty IIII? Yes
No
N
If Yes, nam
me of Certifyin
ng Board:
Date of Ceertification:
Date of Recertification
R
(if applicable):
(m
mm/yy)
(mm/yy)
If No, havee you taken or are you schedu
uled to take thee specialty boarrds certificationn? Yes
If Certifyin
ng Boards taken, give date:
No
Certification Expiration Datte, if Any:
(mm/yy)
((mm/yy)
If not taken
n, date schedulled to take Speccialty Boards:
(mm/yy)
Speciialty/Subspeciialty IV:
Are you Bo
oard Certified in Specialty IV
V? Yes
No
N
If Yes, nam
me of Certifyin
ng Board:
Date of Ceertification:
Date of Recertification
R
(if applicable):
(m
mm/yy)
(mm/yy)
If No, havee you taken or are you schedu
uled to take thee specialty boarrds certificationn? Yes
If Certifyin
ng Boards taken, give date:
No
Certification Expiration Datte, if Any:
(mm/yy)
((mm/yy)
If not taken
n, date schedulled to take Speccialty Boards:
(mm/yy)
Checck here if you have
h
appendeed additional in
nformation fo
or this section::
CURRE
ENT PROFE
ESSIONAL LIABILITY
L
INSURANCE
I
E
This section is blank w
when it
is givenn to the APNs,
but theyy must enter thheir
current professional liiability
insurannce as shown.
CONFID
DENTIAL INF
FORMATION::
Carrier: University of Chicago Medical Center Selff Insured Trustt
Address: _5841 S. Maaryland Ave.
Chicago
C
Street
umber:
Policy Nu
IL
City
State
Original Effeective Date: cotterminus
(mm/dd/yy)
Policy Liimits:
60637
Zip
E
Expiration Datee: w/employmeent
(mm/dd/yyy)
Per Occurrence:
O
$ Aggregate: $
Amounts
are not
f
required for
UCMC tru
ust
Retroactiive Date:
(mm/d
dd/yy)
Check Occu
urrence
What type of coverage do
d you have?
Claims Made
M
xO
Occurrence
Has any judgment
j
or paayment of claim
m or settlementt amount exceeeded the limits of this coveragge?
No
Yes
Circle Yes or No
o
Applic
cant name mus
st either appear on the bottom
m of each page
e or be exclude
ed from
every page.
33
3
Inforrmation listed on
o this page caan serve as anotther way to verrify the numbeer of H-2 Formss needed for eaach packet. A separate H-2
Forrm is needed fo
or each insuran
nce carrier. Alll facilities coveered under the U
UCMC Self-Innsured Trust onnly require onee H-2 Form.
MEMBERSH
M
HIP STATUS
S – USE FOR
R SECTIONS
S C AND D
Please usee the following
g key to indiccate membersship status in Sections C (H
Hospital Mem
mbership – Cu
urrent
and Pendiing) and D (Am
mbulatory Surgery Center Practice)
P
beloow.
A. Active
A
nded / Terminaated/ Resigned
E. Suspen
I. Provisionnal
B. Courtesy
F. Active Provisional Sttaff
J. Affiliate
C. Consulting
G. Seniorr Staff
K. Pendingg
D. Adjunct
A
H. Associiate
L. Other (S
Specify)
SECTIO
ON C. HOSPIITAL MEMBERSHIP - CURRENT A
AND PENDIING
Please list all hospitals at which you are a membeer of the Mediical Staff and
d have clinicall privileges orr have
applications for privileg
ges pending. (Include
(
additio
onal sheets if m
more than threee hospitals.)
APN
must list
A. Primary Hospital
UCMC as
N
Hospital Name:
the
primary
Address:
hospital
Street
S
City
ty
State
Zipp
where
Membersh
hip Status:
Dates:
To Present
they are a
F
From (mm/yy)
member
of the
Departmen
nt/Division:
Medicall Staff Office F
FAX #: ( )
Medical
Departmen
nt Telephone #: ( )
Staff and
have
Any Limitaations in Your Area of Speciaalty at this Hosspital?
clinical
or
pending
privileges.
B. O
Other Hospita
al
Hospital Name:
N
Address:
Street
S
City
ty
Membersh
hip Status:
Dates:
F
From (mm/yy)
Departmen
nt/Division:
State
Zipp
To:
To (mm/yyy)
Medicall Staff Office F
FAX #: ( )
Departmen
nt Telephone #: ( )
Any Limitaations in Your Area of Speciaalty at this Hosspital?
Applic
cant name mus
st either appear on the bottom
m of each page
e or be exclude
ed from
every page.
APN must
list any
other
hospitals
at which
they are a
member
of the
Medical
Staff and
have
clinical
privileges
or
pending
privileges.
34
4
C. O
Other Hospita
al
Hospital Name:
N
Address:
Street
S
City
ty
Membersh
hip Status:
Dates:
From (mm/yy)
F
Departmen
nt/Division:
State
Zipp
To:
To (mm/yyy)
Medicall Staff Office F
FAX #: ( )
Departmen
nt Telephone #: ( )
Any Limitaations in Your Area of Speciaalty at this Hosspital?
If APNs
work at
more than
three
hospitals
they may
attach a
separate
piece of
paper listing
this
information.
Checck here if you have
h
appendeed additional in
nformation fo
or this section::
(Please contiinue next pagee)
Applican
nt name must either
e
appear on
n the bottom off each page orr be excluded frrom
every page.
35
Leav
ve this sheet bllank.
SECTIION D. AMB
BULATORY
Y SURGERY
Y CENTER P
PRACTICE
Please listt all ambulato
ory surgery centers
c
where you currentlly have or prreviously had privileges. U
Use the
Membersh
hip Status key
y at the top of
o page 7. (In
nclude additionnal sheets if m
more than threee ambulatory ssurgery
centers.)
A) P
Primary Ambu
ulatory Surgeery Center
ASC Namee:
Address:
Street
S
Citty
Telephone: ( )
State
Ziip
Fax Numberr: ( )
hip Status:
Membersh
Dates:
To:
F
From (mm/yy)
To (mm/yyy)
B) O
Other Ambula
atory Surgery Center
ASC Namee:
Address:
Street
S
Citty
Telephone: ( )
State
Ziip
Fax Numberr: ( )
hip Status:
Membersh
Dates:
To:
F
From (mm/yy)
To (mm/yyy)
C) O
Other Ambula
atory Surgery Center
ASC Namee:
Address:
Street
S
Citty
Telephone: ( )
State
Ziip
Fax Number:: ( )
Membersh
hip Status:
Dates:
To:
From (mm/yy)
F
To (mm/yyy)
h
appendeed additional in
nformation fo
or this section::
Checck here if you have
(Please contiinue next pagee)
Applican
nt name must either
e
appear on
n the bottom off each page orr be excluded frrom
every page.
36
SE
ECTION E. WORK
W
HIST
TORY
List chronologically (m
most recent first)
f
all worrk engagemen
nts (includingg employmen
nt, self-employyment,
service ass an independ
dent contractor, and military service) iin the last foour (4) years.. Do not duplicate
internship
p, residency, and
a fellowship
p information previously reeported. If there is any gap
p of greater th
han 30
days in chronology, exp
plain it on a sep
parate page.
Currrent work placce: University of Chicago Medical
M
Centerr
Address: 5841
5
S Mary
yland Avenu
ue
Ch icago
Street
S
Telephone: ( )
IL 60
0637
Citty
State
Ziip
Citty
State
Ziip
APNs
must list their
current place
of work. Be
sure to list
UCMC as
current work
place. Note:
You only
need to list
places worked
since last
Appointment.
Fax
x Number: ( )
Title or Pro
ofessional Occupation:
Time in thiis employmentt: From:
to Prresent
(mm/y
yy)
Previious work placce:
Address:
Street
S
Telephone: ( )
Fax Number: ( )
ofessional Occupation:
Title or Pro
Time in thiis employmentt: From:
to:
(mm/y
yy)
(mm/yy)
Previious work placce:
Address:
Street
S
Telephone: ( )
ty
City
State
Zipp
Citty
State
Ziip
Fax Numberr: ( )
ofessional Occupation:
Title or Pro
to:
Time in thiis employmentt: From:
(mm/y
yy)
(mm/yy)
Previious work placce:
Address:
Street
S
Telephone: ( )
Fax Numberr: ( )
ofessional Occupation:
Title or Pro
Time in thiis employmentt: From:
to:
(mm//yy)
(mm/yy)
Applican
nt name must either
e
appear on
n the bottom off each page orr be excluded frrom
every page.
37
7
APNs may leave this sheeet blank
SECTION F.
F MEDICAL
L EDUCATIION/CLINIC
CAL TRAIN
NING UPDAT
TE
Please pro
ovide an upda
ate of your medical
m
educattion and cliniccal training oover the past four years. D
Do not
duplicate internship, reesidency, and fellowship in
nformation prreviously repoorted. (Attachh additional shheets if
necessary.))
FIRST UPDATE
U
Residency
Fellowsh
hip
Other
O
Instituution Name:
Depaartment Chair or
o Program Direector:
Last Nam
me
Firstt Name
MI
Degree
Mailiing Address:
Sttreet
Datess attended:
State
City
Telepphone Number:: ( )
Zipp
Fax Num
mber: ( )
From:
F
To:
mm/yy
Type of in
nternship:
mm/y
yy
Ro
otating
Sttraight
Did you su
uccessfully com
mplete this program?
Iff straight, pleasse list specialtyy:
Yes
No
If no, pleaase attach an exxplanation.
Weree you the subjecct of any discip
plinary action during
d
your atteendance at thiss institution?
Yes
No
(Attach an
n explanation oof a “Yes” answ
wer.)
SECON
ND UPDATE
Fellowsh
hip
Residency
Other
O
Instituution Name:
Depaartment Chair or
o Program Direector:
Last Nam
me
Firstt Name
MI
Degree
Mailiing Address:
Sttreet
City
Telepphone Number:: ( )
Datess attended:
State
Zipp
Fax Num
mber: ( )
From:
F
To:
mm/yy
Type of in
nternship:
Ro
otating
mm/yy
Sttraight
Did you su
uccessfully com
mplete this program?
Iff straight, pleasse list specialtyy:
Yes
No
If no, pleaase attach an exxplanation.
Weree you the subjecct of any discip
plinary action during
d
your atteendance at thiss institution?
Yes
No
(Attach an
n explanation oof a “Yes” answ
wer.)
Checck here if you have
h
appendeed additional in
nformation fo
or this section::
Applica
ant name must either appear on
o the bottom o
of each page o
or be excluded from
every page.
38
SECT
TION G. PRO
OFESSIONA
AL HISTOR
RY: CONFID
DENTIAL
ADVERSE OR OTHER AC
CTIONS
APN must aanswer each quuestion in this section. If
APNs answ
wer “Yes” to anny of the questiions, they will have to
complete Foorm A.
ns to the bestt of your knoowledge with a “yes” or
S
Submit with all
a application
ns. Please ansswer the follo
owing question
““no.” If you answer
a
“yes” to any questio
on(s) please co
omplete Form
m A. Please m
make copies off Form A as n
needed and
ccomplete one form
f
for each “yes” answer.
P
Please providee information on your profeessional history
y over the passt four (4) yearrs.
1.
Has your liccense to practtice in any jurrisdiction everr been denied , restricted,
limited, susspended, revoked, canceled
d and/or subjject to probaation either
voluntarily or
o involuntarilly, or has you
ur application for a licensee ever been
withdrawn?
Yes
N
No
Have you beeen reprimandeed and/or fined
d, been the subjject of a compplaint and/or
have you beeen notified in writing
w
that you have been in
nvestigated as tthe possible
subject of a criminal, civill or disciplinarry action by an
ny state or fedderal agency
which licenses providers?
Yes
N
No
3.
Have you losst any board ceertification(s), and/or
a
failed to
o recertify?
Yes
N
No
4.
Have you been examined by
b a Certifying Board but faileed to pass?
Yes
N
No
5.
Has any info
ormation pertaaining to you, including
i
malp
practice judgm
ments and/or
disciplinary action, ever been
b
reported to
t the Nationaal Practitioner Data Bank
(NPDB) and
d/or any other practitioner
p
dataa bank?
Yes
N
No
Has your fed
deral DEA nu
umber and/or state
s
controlled
d substances liicense been
restricted, liimited, relinqu
uished, suspen
nded or revok
ked, either volluntarily or
involuntarily
y, and/or have you ever been
n notified in writing
w
that youu are being
investigated as the possib
ble subject of a criminal orr disciplinary aaction with
our DEA or con
ntrolled substan
nce registration?
respect to yo
Yes
N
No
Have you, orr any of your hospital
h
or amb
bulatory surgery center priviilegesand/or
membership been denied, revoked, susp
pended, reducced, placed onn probation,
proctored, pllaced under maandatory consu
ultation or non-rrenewed?
Yes
N
No
Have you vo
oluntarily or in
nvoluntarily rellinquished or failed
f
to seek rrenewal of
your hospitall or ambulatory
y surgery centeer privileges for any reason?
Yes
N
No
Have any disciplinary actio
ons or proceed
dings been insttituted against you and/or
are any discciplinary action
ns or proceediings now pend
ding with resppect to your
hospital or am
mbulatory surg
gery center priivileges and/or your license?
Yes
N
No
Have you beeen reprimandeed, censured, excluded,
e
suspended and/or ddisqualified
from particiipating, or vo
oluntarily with
hdrawn to av
void an investtigation, in
Medicare, Medicaid,
M
CHA
AMPUS and/or any other go
overnmental heealth-related
programs?
Yes
N
No
Yes
N
No
2.
6.
7.
8.
9
10.
11.
Have Medicare, Medicaid,, CHAMPUS, PRO authoritiies and/or anyy other third
party payorss brought charges against yo
ou for alleged inappropriate fees and/or
quality-of-caare issues?
Applica
ant name must either appear on the bottom of each page o
or be excluded
d from
every page.
39
9
12.
13.
Have you beeen denied mem
mbership and/o
or been subject to probation, rreprimand,
sanction or disciplinary
d
acttion, or have you
y ever been notified
n
in wriiting that you aare
being investigated as the possible
p
subjecct of a criminaal or disciplinaary action by aany
health care organization,
o
e..g. hospital, HM
MO, PPO, IPA
A, professional group or socieety,
licensing boaard, certificatio
on board, PSRO
O, or PRO?
Y
Yes
No
Have you withdrawn
w
an application
a
or any
a portion off an applicationn for appointm
ment
or reappointtment for clin
nical privilegees or staff appointment or for a licensee or
membership in an IPA, PH
HO, professionaal group or socciety, health caare entity or heealth
care plan prior to a finaal decision to avoid a proffessional revieew or an adveerse
decision?
Y
Yes
No
PRO
OFESSIONA
AL LIABILIITY ACTION
NS
APNs musst answer each question in this section. If “Y
Yes” is
answered too any question,, they will havee to complete F
Form B.
IIf you answer yes to any queestion(s) in thiis section please complete F
FORM B. Pleaase make copies of FORM B if
n
needed, and co
omplete one fo
or each yes answer.
1.
Have any pro
ofessional liabiility judgmentss ever been enteered against yoou?
Y
Yes
No
2.
Have any pro
ofessional liabiility claim settllements ever beeen paid by yo u and/or paid oon
your behalf?
Y
Yes
No
Are there any
y currently pen
nding professio
onal liability su
uits, actions andd/or claims fileed
against you?
Y
Yes
No
our clinical actions?
Has any persson or entity beeen sued for yo
Y
Yes
No
3.
4.
LIA
ABILITY INSURANCE
These
answers must
be consisstent
with the
yes/no
answers
provided
d on
page 10
(Applicatio
on for
Reappointm
ment).
AP
PNs must answ
wer this questioon. If
“Y
Yes” is answereed, they will haave to
coomplete Form C
C.
y to this question please co
omplete FORM
M C.
Iff you answer yes
Havve you been denied
d
or volu
untarily relinqu
uished your professional
p
liaability insurannce
coveerage, and/or have had your professional liability insurrance coveragee canceled, noonreneewed or limits reduced?
r
CR
RIMINAL AC
CTIONS
Y
Yes
No
APNs m
must answer eaach question inn this section. IIf “Yes”
is answ
wered, they willl have to compplete Form D.
IIf you answerr yes to any question(s)
q
in this section please
p
complette FORM D. Please makee copies of FO
ORM D if
n
needed, and co
omplete one fo
or each yes answer.
1.
2.
Have you been
b
charged with
w
or convicted of a crim
me (other thann a minor traaffic
offense) in th
his or any otheer state or cou
untry and/or do
o you have anyy criminal charrges
pending otheer than minor trraffic offenses in this state or any other statee or country?
Y
Yes
No
Have you beeen the subjectt of a civil or criminal
c
comp
plaint or adminnistrative actionn or
been notified
d in writing th
hat you are beeing investigatted as the posssible subject at a
civil, crimin
nal or adminisstrative action
n regarding seexual miscondduct, child abuuse,
domestic vio
olence or elder abuse?
Y
Yes
No
Applic
cant name mus
st either appearr on the bottom
m of each page or be excluded
d from
every page.
40
0
ME
EDICAL CON
NDITION
IIf you answer yes to this queestion please complete
c
FOR
RM E.
APNs must answer this
question. If “Yes” is
answered, thhey will have tto
complete Foorm E.
Do you have a medical
m
conditio
on, physical deefect or emotiional impairmeent which in aany
or limits your ab
bility to practicce medicine wiith reasonable sskill and safetyy?
wayy impairs and/o
Y
Yes
No
APNs mu
must answer thhe questions in this
section. Iff “Yes” is answ
wered, they wiill have
to compleete Form F.
CH
HEMICAL SU
UBSTANCES OR ALCO
OHOL ABUS
SE
IIf you answerr yes to any question(s)
q
in this section please
p
compleete FORM F. Please makee copies of FO
ORM F if
n
needed, and co
omplete one fo
or each yes answer.
1.
Are you currrently engaged in illegal use of
o any legal or illegal substannces?
Y
Yes
No
2.
Do you curreently overuse and/or
a
abuse alccohol or any otther controlledd substances?
Y
Yes
No
3.
If you use alccohol and/or ch
hemical substaances, does you
ur use in any w
way impair andd/or
limit your ab
bility to practice medicine witth reasonable sk
kill and safety??
Y
Yes
No
4.
Are you cu
urrently particcipating in a supervised rehabilitation
r
program andd/or
professional assistance pro
ogram which monitors you for alcohol aand/or substannce
abuse?
Not A
Applicable
Y
Yes
No
APNs mustt answer this quuestion. If “Yes” is answeredd, they
will have too provide an exxplanation.
INV
VESTMENT
TS
In thhe last five (4) years have you
y and/or a member
m
of you
ur family purchhased or madee an
inveestment in (oth
her than securrities of a pub
blicly traded company),
c
or otherwise havve a
busiiness interest in
n any clinical laboratory,
l
diaagnostic or testting center, hosspital, surgicennter,
and//or other busin
ness dealing wiith the provisio
on of ancillary
y health servic es, equipment or
suppplies?
Y
Yes
No
If Yees, please prov
vide explanatio
on:
(P
(Please continu
ue next page)
App
plicant name must either appe
ear on the botto
om of each pag
ge or be exclud
ded from
every page
e.
41
CHAPTER
C
R B:
BUSINE
ESS INFO
ORMATIO
ON
SECTION H. PRIMA
ARY SITE IN
NFORMATIION
ormation for the
t primary siite at which yoou practice.
Pleasse provide the following info
Prim
mary
Siite
Group/Business Name
N
Primary
site should
always be
UCMC.
APNs must
provide all
of the
requested
information.
Buillding Name
Offiice Address – Number
N
and Sttreet – Suite
City
y
County
( )
Maiin Telephone Number
N
( )
FAX
F
Number
( )
Emeergency Number
( )
Answering
A
Serv
vice
Are yyou currently acccepting new patients
p
at this location?
l
Ziip
Firrst
Office
O
Adminisstrator – Last
( )
Beeeper Number
State
MI
E -mail
Yes
No
Iff yes, describe any restrictions (e.g., appointtment type, pattient type):
n
of activ
ve patients enro
olled with you at this site:
Please provide the number
Please provide the number
n
of patieent visits you have
h
at this sitee per year:
List aany special sk
kills or qualiffications you or
o your officee staff have th
hat enhance yyour ability too practice meedicine or trea
at
certaain patients orr classes of patients. List separately an
ny special lan guage skills, such as fluen
ncy in a foreiggn language or
o
profiiciency in sign language.
S
Special Skills of
o Practitioner:
S
Special Skills of
o Staff:
L
Languages Spo
oken by Practitiioner:
L
Languages Wriitten by Practitiioner:
Questiions in this
sectionn can be
left blaank.
L
Languages Spo
oken by Staff:
L
Languages Wriitten by Staff:
ext page)
(Pleasse continue nex
Applica
ant name must either appear on the bottom of each page o
or be excluded
d from
every page.
42
2
APN may
y leave this pagge blank.
Pleasse provide the following infformation about physician(ss)/practitionerr(s) who proviide coverage ffor patients en
nrolled at thiss
site w
when you are not
n available.
Namee:
Firstt
Last
MI
Degrree
Specialty:
Address:
Telepphone: ( )
Street
S
Availabilitty:
Days
Nights
City
Weekends
Statee
Holidays
Zip
CONFIDE
ENTIAL INFO
ORMATION: Tax ID #:
Namee:
Firstt
Last
MI
Degrree
Specialty:
Address:
Street
S
Availabilitty:
Days
Nights
City
Weekends
Statee
Holidays
Telephone: ( )
Zip
CONFIDE
ENTIAL INFO
ORMATION: Tax ID #:
Namee:
Firstt
Last
MI
Degrree
Specialty:
Address:
Street
S
Availabilitty:
Days
Nights
City
Weekends
Statee
Holidays
Telephone: ( )
Zip
CONFIDE
ENTIAL INFO
ORMATION: Tax ID #:
(Please contiinue next pagee)
Applica
ant name must either appear on the bottom of each page o
or be excluded
d from
every page.
43
3
APN will on
nly need to com
mplete this pag
ge if they work at additional ssites. (NOT RE
EQUIRED)
SECTION I.. ADDITION
NAL SITE IN
NFORMATIION
Pleasse provide the following info
ormation for each
e
additiona
al site at which
h you practicee.
Siite
#
Group/Business Name
N
Buillding Name
Offiice Address – Number
N
and Sttreet – Suite
City
y
County
( )
N
Maiin Telephone Number
Office
O
Adminisstrator – Last
( )
Beeeper Number
( )
FAX
F
Number
( )
Emeergency Number
( )
Answering
A
Serv
vice
Are yyou currently acccepting new patients
p
at this location?
l
Statee
Firrst
E -mail
Yes
Zip
MI
Questions
in this
section
can be
left blank.
No
Iff yes, describe any restriction
ns (e.g., appointtment type, pattient type):
n
of activ
ve patients enro
olled with you at this site:
Please provide the number
Please provide the number
n
of patieent visits you have
h
at this sitee per year:
List aany special sk
kills or qualiffications you or
o your officee staff have th
hat enhance yyour ability too practice meedicine or trea
at
certaain patients orr classes of patients. List separately an
ny special lan guage skills, such as fluen
ncy in a foreiggn language or
o
profiiciency in sign language.
S
Special Skills of
o Practitioner:
S
Special Skills of
o Staff:
L
Languages Spo
oken by Practitiioner:
L
Languages Wriitten by Practitiioner:
L
Languages Spo
oken by Staff:
L
Languages Wriitten by Staff:
(Please conttinue next pagge)
Applican
nt name must either
e
appear on
o the bottom o
of each page orr be excluded ffrom
every
e
page.
44
4
APN
Ns may leave th
his page blank..
Pleasse provide the following infformation about physician(ss)/practitionerr(s) who prov ide coverage ffor patients en
nrolled at thiss
site w
when you are not
n available.
Namee:
Firstt
Last
MI
Degrree
Specialty:
Address:
Street
S
Availabilitty:
Days
Nights
City
Weekends
Statee
Holidays
Telephone: ( )
Zip
CONFIDE
ENTIAL INFO
ORMATION: Tax ID #:
Namee:
Firstt
Last
MI
Degrree
Specialty:
Address:
Street
S
Availabilitty:
Days
Nights
City
Weekends
Statee
Holidays
Telephone: ( )
Zip
CONFIDE
ENTIAL INFO
ORMATION: Tax ID #:
Namee:
Firstt
Last
MI
Degrree
Specialty:
Address:
Street
S
Availabilitty:
Days
Nights
City
Weekends
Statee
Holidays
Telephone: ( )
Zip
CONFIDE
ENTIAL INFO
ORMATION: Tax ID #:
End Recredenttialing and Business D
Data Gatheering Form
m.
Atttach Form
ms A-F As R
Required.
Applicant name mu
ust either appe
ear on the botto
om of each pag
ge or be exclud
ded from
every page .
45
APNs must complete this paage if they answ
wered “Yes” to
o a question in the Adverse an
and Other Actioons section.
FORM A – AD
DVERSE AND
D OTHER ACT
TIONS
ATE this form
m as necessarry to completee separate sh
heet for EACH
H occurrence that applies.. Use
DUPLICA
reverse sid
de of this form
m if additional space is needed.
Appliicant Name:
Last
First
M
MI
Indicaate the numberr of ONE of thee questions in Section
S
J to whhich you answeered “yes”: Quuestion Numbeer:
A. D
Describe the circcumstances surrrounding this occurrence. Please include thhe date of the ooccurrence.
B. Prrovide an explaanation of any actions taken. Please includee the date the aaction was takeen.
C. Prrovide the currrent status of th
he issue.
D. Iff known:
Co
ontact:
Department/Com
D
mmittee:
Address:
A
Streeet
State
Citty
Telephone: ( )
Signaature:
Date:
Zipp
If this form haas been
completed, A
APN
must sign andd date.
Applicant name must eitther appear on the bottom of each page or b
be excluded fro
om
very page.
ev
46
APN
N must complette this page if they
t
answered “Yes” to a queestion in the Prrofessional Liabbility Actions section. All fieelds must
be ccompleted on th
his page.
BILITY ACTIONS
FORM B – PROFESSIIONAL LIAB
DUPLICA
ATE this form
m as necessary to complete a separate sheeet for EACH aaction or alleggation. Use reeverse
side of thiss form if addittional space iss needed.
Appliicant Name:
Last
First
M
MI
First
M
MI
A. Pllaintiff’s Namee:
Last
If court casse, Case Name & Case Numbber:
B. Y
Your Involvemeent in the Care (Attending, Co
onsulting, Etc.)):
C. Y
Your Status in th
he Case (Sole Defendant,
D
Co--Defendant, Ow
wnership Intereest in Providerr Practice Namee in
Suuit, Etc.):
D. A
Allegations, inclluding Patient Outcome, if Av
vailable:
E. Date of Incidentt (mm/yy):
If this form
has been
completed,
E through H
are required.
F. Date Filedd (mm/yy):
G. D
Date Case Closeed (mm/yy):
R
Resolution Casee:
Dismisssed
Settlem
ment out of Cou
urt
Judgm
ment
Pend
ding
Arrbitration
M ediation
H. A
Amount Paid on
n Your Behalf (if
( any): $
I. Proofessional Liab
bility Insurer Name
N
(if one waas involved):
J. Inssurer Telephon
ne Number: ( )
Other
APN must provide
informationn for letters
I through L
L,
which shouuld correlate
with the H--2 form.
K. Policy Numbeer:
L. Innsurer Address (Street, City, State,
S
Zip Codee):
If this form hhas been
completed, A
APNs
must sign annd date.
Signaature:
Date:
Applic
cant name mus
st either appea
ar on the bottom
m of each page
e or be exclude
ed from
every page.
47
7
APN
N must compllete this page iff they answered “Yes” to a quuestion in the L
Liability Insuraance section.
FORM
M C – LIABILIITY INSURAN
NCE
DUPLICA
ATE this form
m as necessary to complete a separate sheeet for EACH aaction or alleggation. Use reeverse
side of thiss form if addittional space iss needed.
Appliicant Name:
Last
First
M
MI
A. H
History of Proffessional Liabiility Insurancee (Please check
k One)
Canceled Voluntarily
V
Non-Reenewed
Canceled Involuntarily
I
Applicattion Denied
B. Carrier Name:
C. Caarrier Telephon
ne Number: ( )
D. Poolicy Number:
E. Caarrier Address (Street, City, State,
S
Zip Codee):
F. Daates of Coverag
ge:
From (m
mm/yy):
To (mm/yy):
G. Ciircumstances In
nvolved:
If this form haas been
completed, APN must
sign and date..
Signaature:
Date:
Applicant name
n
must eith
her appear on the
t bottom of e
each page or b
be excluded from
eve
ery page.
48
APN must
m complete this page if they answered “Y
Yes” to a questtion in the Crim
minal Actions ssection.
FORM
M D – CRIMIINAL ACTION
NS
DUPLICA
ATE this form
m as necessary to complete a separate sheeet for EACH iincident. Use reverse side oof this
form if ad
dditional spacee is needed.
Appliicant Name:
Last
First
M
MI
A. D
Date of Incidentt (mm/yy):
Date of Complaiint or Conviction (mm/yy):
B. D
C. Date of Resolutiion (mm/yy):
d, Plea Bargain
n, Misdemeano
or, Felony):
D. Tyype of Resoluttion (Dismissed
E. Alllegation(s):
F. Deetails of Incideent:
Actions Taken Against
A
You:
G. A
H. C
Current Status of
o Situation:
If this form has beenn
complleted, APN muust
sign aand date.
ult of This Situ
uation:
I. Meedical Practice Privileges Afffected as a Resu
Signaature:
Date:
Applic
cant name mus
st either appea
ar on the bottom
m of each page
e or be exclude
ed from
every page.
49
9
APNss must complette this page if they answered “Yes” to a queestion in the Meedical Conditioon section.
FORM
M E – MEDICA
AL CONDITIION
DUPLICA
ATE this form
m as necessary
y to complete a separate sh
heet for EACH
H condition. U
Use reverse siide of
this form if
i additional space is needed
d.
Appliicant Name:
Last
First
M
MI
A. D
Describe this meedical conditio
on:
B. Too what extent does
d
or could th
his condition affect
a
your currrent ability to ppractice mediciine in your speccialty
arrea or to perforrm a full range of clinical actiivities?
C. W
What is the current status of yo
our condition?
D. Prrovide the nam
me and address of your person
nal physician/health care provvider who can pprovide inform
mation about yoour health
coondition.
Name
Teleephone Number
( )
Laast
First
MI
Degreee
Laast
First
MI
Degreee
( )
Signaature:
If this form hhas been
completed,
APN
must sign andd date.
Date:
Applicantt name must eiither appear on
n the bottom off each page or be excluded frrom
ev
very page.
50
0
APN
A
must com
mplete this pagee if they answerred “Yes” to a question in thee Chemical Subbstances or
Alcoho
ol Abuse sectioon.
FORM F – CHEMICA
AL SUBSTAN
NCES OR ALC
COHOL ABU
USE
DUPLICA
ATE this form
m as necessary to complete a separate sheeet for EACH cchemical substtance
incident. Use
U reverse siide of this form
m if additionall space is need
ded.
Appliicant Name:
Last
First
M
MI
Descrribe the substan
nce you use:
A. To what extent does,
d
or could, your use of this substance afffect your curreent ability to prractice medicinne in your
sspecialty area or
o to perform a full range of clinical
c
activitiees?
Monitored by Sttate Board Man
ndate (Name an
nd Address)
B. M
C. Monitoredd Voluntarily (N
Name and Address)
Other informatio
on about the cu
urrent status off your use of su
ubstances:
D. O
(
E. Abbstinent since (mm/yy):
F. Prrovide the nam
me and address of your person
nal physician/h
health care proovider who cann provide inforrmation about your treatmentt
foor alcohol or ch
hemical substan
nce use and can
n comment on what impact (iif any) it has onn your current//future professiional practice.
Name:
Address:
Street
S
Telephone: ( )
Signaature:
City
State
Ziip
If this form hhas been
completed, A
APN must
sign and datte.
Date:
App
plicant name must either appe
ear on the botto
om of each pag
ge or be exclud
ded from
every page
e.
51
Common Links Used for the Recredentialing Application
IDPH State of Illinois Form (recredentialing)- http://www.idph.state.il.us/about/credentialing.htm
ProCred Report- http://corecompetency.uchicago.edu The physician will have to use their CNet ID
and password to login the system.
NPI Number- https://nppes.cms.hhs.gov/NPPES/NPIRegistrySearch.do?subAction=reset&searchType=ind
License Lookup: https://www.idfpr.com/licenselookup/licenselookup.asp
52