Illinois Credentialing Application

Chapter B: Business Information
Section K: Primary Site Information

Please provide the following information for the primary site at which you practice.
Group/Business Name:
Building Name:
Address:

Street Address

County

CityState

Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Number:
Please enter a valid phone number.Format: (000) 000-0000.
Answering Service:
Please enter a valid phone number.Format: (000) 000-0000.
Office Administrator:

First NameLast Name
Email:
example@example.com
Specialty practiced at this site:
YesNo
Please describe the restrictions:
Briefly describe your practice at this location, including any special practice focus or equipment:
YesNo
Please describe the restrictions (e.g. appointment type, patient type):
Please provide the number of active patients enrolled with you at this site:
Please provide the number of patient visits you have at this site per year:

Office Hours:*

Rows	Open	Close
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Please indicate standard patient waiting times to schedule an appointment at this site for:

Rows	New Patient	Existing Patient
Emergency Care
Urgent Care
Symptomatic Care (e.g. sore throat)
Routine Visit (e.g. blood pressure check)
Preventive Routine Care (e.g. school or annual pysical)

Maximum number of appointments per hour:
Average waiting time in office (from scheduled appointment time to actual examination):
Average response time for returning patient calls:
Acute or urgent situation:
Emergency situation:
Routine call:
Age-appropriate immunizationsEKGDrawing bloodTympanometry/audiometry screeningX-raysMinor surgeryPulmonary function studiesFlexible sigmoidoscopyLaceration repairOffice gynecology (routine pelvic/PAP)Asthma treatmentAllergy skin testin gOsteopathic /Chiropractic manipulationIV hydration/treatmentPhysical Therapy
List any special skills or qualifications you or your office staff have that enhance your ability to practice medicine or treat certain patients or classes of patients. List separately any special language skills, such as fluency in a foreign language or proficiency in sign language.
Special Skills of Practitioner:
Special Skills of Staff:
Languages Spoken by Practitioner:
Languages Written by Practitioner:
Languages Spoken by Staff:
Languages Written by Staff:
BuildingParkingWheelchairRestroom
YesNo
YesNo
YesNo
If yes, list Tax ID Numbers used:
YesNo
PrimarySecondaryTertiary
YesNo
If yes, CLIA Expiration Date:

MonthDayYear
Date
YesNo
Name:

First NameLast Name
Degree:
Specialty:
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
DaysNightsWeekendsHolidays
Tax ID Number:
YesNo
Name

First NameLast Name
Degree:
Specialty:
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
DaysNightsWeekendsHolidays
Tax ID Number:
YesNo
Name:

First NameLast Name
Degree:
Specialty:
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
DaysNightsWeekendsHolidays
Tax ID Number:
YesNo
Name:

First NameLast Name
Specialty:
YesNo
Name:

First NameLast Name
Specialty:
YesNo
Name:

First NameLast Name
Specialty:

Section L: Primary Site Tax Information

Please provide the following information for your Primary Site. Include tax information foreach business arrangement you use at this site.
Business Arrangement #1
Name of Business Arrangement On SS4 or W -9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
Tax ID for this arrangement:
Billing address, if different from primary site:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number, if different from primary site:
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Business Arrangement #2
Name of Business Arrangement On SS4 or W -9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
Tax ID for this arrangement:
Billing address, if different from primary site:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number, if different from primary site:
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Business Arrangement #3
Name of Business Arrangement On SS4 or W -9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
Tax ID for this arrangement:
Billing address, if different from primary site:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number, if different from primary site:
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Business Arrangement #4
Name of Business Arrangement On SS4 or W -9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
Tax ID for this arrangement:
Billing address, if different from primary site:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number, if different from primary site:
Please enter a valid phone number.Format: (000) 000-0000.
YesNo

Section N: Additional Site Tax Information

Please provide the following information for each additional site at which you practice. Include tax information for each business arrangement you use at this site.
Business Arrangement #1
Name of Business Arrangement On SS4 or W -9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
Tax ID for this arrangement:
Billing address, if different from primary site:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number, if different from primary site:
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Business Arrangement #2
Name of Business Arrangement On SS4 or W -9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
Tax ID for this arrangement:
Billing address, if different from primary site:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number, if different from primary site:
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Business Arrangement #3
Name of Business Arrangement On SS4 or W -9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
Tax ID for this arrangement:
Billing address, if different from primary site:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number, if different from primary site:
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Business Arrangement #4
Name of Business Arrangement On SS4 or W -9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
Tax ID for this arrangement:
Billing address, if different from primary site:

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number, if different from primary site:
Please enter a valid phone number.Format: (000) 000-0000.

Authorization and Consent for Release of Information:
I hereby specifically authorize and consent for the following organizations to release to Gadrian Corporation any and all records and information in your possession, which relates to my credentials as a physician and/or healthcare provider. The purpose of this authorization and consent to release is to permit Gadrian Corporation to properly gather and verify my credentials to engage in the delivery healthcare or practice medicine.
State Licensing Organizations
License, Sanctions, State Requirements for Licensing, Education
Universities/Colleges/Graduate
Education and Training
Hospitals/Medical Facilities
Appointment Date/Privileges/Restrictions/Residency – Fellowship – Internship
Professional Liability Carrier
Certificate of Insurance that includes my professional liability insurance coverage history, which includes policy number, effective dates, limits of liability, and retroactive date.
Additional
The National Practitioner Data Bank, Federation of State Medical Boards, and Medicare/Medicaid for sanctions.

The purpose of this authorization and consent to release is to permit Gadrian Corporation to properly gather and verify my credentials in accordance with the guidelines established by the National Committee on Quality Assurance (NCQA) and the Joint Commission Accreditation for Hospital Organizations (JCAHO I hereby authorize and consent to Gadrian Corporation providing any and all such information concerning my credentials to the healthcare organization, i.e., HMO, PPO, Hospital, etc., seeking to credential me for healthcare privileges. I hereby release any and all individuals, organizations and entities from any and all liability which might arise from their furnishing such information and records to a third-party if such release is done at my request.

I agree to notify Gadrian Corporation of any change in information.

I agree that this authorization and consent shall remain valid and in full force and effect until specifically withdrawn by me in writing.

I agree that a photocopy of this document will serve as a duplicate original.
Name:*

First NameLast Name
Signature:*

Clear
Date:*

MonthDayYear
Date
State License Number:*
Should be Empty:

Chapter B: Business Information

Section K: Primary Site Information

Average response time for returning patient calls:

Section L: Primary Site Tax Information

Business Arrangement #1

Business Arrangement #2

Business Arrangement #3

Business Arrangement #4

Section M: Additional Site Information

Average response time for returning patient calls:

Section N: Additional Site Tax Information

Business Arrangement #1

Business Arrangement #2

Business Arrangement #3

Business Arrangement #4

Authorization and Consent for Release of Information:

State Licensing Organizations

Universities/Colleges/Graduate

Hospitals/Medical Facilities

Professional Liability Carrier

Additional