Applicant's Signature (or electronic signature)

Type or Print Name

Date

Name:

Last

First

MI

Degree MD/DO/DC/PhD/MSW/DPM/ DDS/DMD/Other

List other names by which you have been known: 

Last

First

MI

If you have been known by other names, please explain why your name changed:

Birth Date:

Place of Birth:

(mm/dd/yy)

City

State

Country

Sex:

 Male

 Female

Language Fluency of Applicant:

 English

 Other______

 Spanish

U.S. Citizen?

 Yes

 No

If "no", do you have a legal right to reside permanently and work in the U.S.?

 Yes

 No

CONFIDENTIAL INFORMATION

Resident Visa No:

Medical Education Number:

Emergency Contact Person:

Last

First

MI

Telephone Number:

(          )

Mailing Address:

Daytime Phone:

(          )

EMAIL Address:

Fax Number:

(          )

Check here if you have appended additional information for this Section. 

Illinois Professional License Number:

Unrestricted License?

 Yes

 No

If "no", please explain restriction(s)

Current and Previous Professional Licenses in Other States

State:

License #

Exp. Date:

(mm/dd/yy)

Unrestricted License?

 Yes

 No

If "no", please explain restriction(s)

State:

License #

Exp. Date:

(mm/dd/yy)

Unrestricted License?

 Yes

 No

If "no", please explain restriction(s)

State:

License #

Exp. Date:

(mm/dd/yy)

Unrestricted License?

 Yes

 No

If "no", please explain restriction(s)

Check here if you have appended additional information for this section.

Current Federal DEA License Number:

CONFIDENTIAL INFORMATION

DEA License Number Expiration Date:

Unrestricted License?

 Yes

 No

(mm/dd/yy)

If "no", please explain restriction(s):

Check here if you have appended additional information for this section.

Current and Previous State Controlled Substance Numbers:

CONFIDENTIAL INFORMATION

State:

CS License #:

Expiration Date:

(mm/dd/yy)

State:

CS License #:

Expiration Date:

(mm/dd/yy)

State:

CS License #:

Expiration Date:

(mm/dd/yy)

Please identify all limitations related to the above Controlled Substances Numbers and explain limitations

Medicare Unique Provider ID# (UPIN):

National Provider Identification Number (NPI):

Medicaid ID#:

X-Ray Certification:

State:

Certificate #:

Expiration Date:

(mm/dd/yy)

Check here if you have appended additional information for this section.

Specialty I:

Are you Board Certified in Specialty I?

 Yes

 No

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if applicable):

(mm/yy)

(mm/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

 Yes

 No

If Certifying Boards taken, give date:

(mm/yy)

Certification Expiration Date, If Any:

(mm/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/yy)

Specialty/Subspecialty II:

Are you Board Certified in Specialty/Subspecialty II?

 Yes

 No

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if applicable):

(mm/yy)

(mm/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

 Yes

 No

If Certifying Boards taken, give date:

(mm/yy)

Certification Expiration Date, If Any:

(mm/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/yy)

Specialty/Subspecialty III:

Are you Board Certified in Specialty/Subspecialty III?

 Yes

 No

Are you Board Certified in Specialty III?

 Yes

 No

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if applicable):

(mm/yy)

(mm/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

 Yes

 No

If Certifying Boards taken, give date:

(mm/yy)

Certification Expiration Date, If Any:

(mm/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/yy)

Specialty/Subspecialty IV:

Are you Board Certified in Specialty/Subspecialty IV?

 Yes

 No

Are you Board Certified in Specialty IV?

 Yes

 No

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if applicable):

(mm/yy)

(mm/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

 Yes

 No

If Certifying Boards taken, give date:

(mm/yy)

Certification Expiration Date, If Any:

(mm/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/yy)

Check here if you have appended additional information for this section.

Carrier:

Address:

Street

City

State

Zip

Policy Number (last 4 digits):

Original Effective Date:

Expiration Date:

(mm/dd/yy)

(mm/dd/yy)

Policy Limits:

Per Occurrence:

$

Aggregate:

$

Retroactive Date:

(mm/dd/yy)

What type of coverage do you have?

 Claims Made

 Occurrence

Has any judgement or payment of claim or settlement amount exceeded the limits of this coverage?

Yes

No

PREVIOUS PROFESSIONAL LIABILITY INSURANCE

CONFIDENTIAL INFORMATION:

Carrier:

Address:

Street

City

State

Zip

Policy Number (last 4 digits):

Original Effective Date:

Expiration Date:

(mm/dd/yy)

(mm/dd/yy)

Policy Limits:

Per Occurrence:

$

Aggregate:

$

Retroactive Date:

(mm/dd/yy)

What type of coverage do you have?

 Claims Made

 Occurrence

Has any judgement or payment of claim or settlement amount exceeded the limits of this coverage?

Yes

No

Carrier:

Address:

Street

City

State

Zip

Policy Number (last 4 digits):

Original Effective Date:

Expiration Date:

(mm/dd/yy)

(mm/dd/yy)

Policy Limits:

Per Occurrence:

$

Aggregate:

$

Retroactive Date:

(mm/dd/yy)

What type of coverage do you have?

 Claims Made

 Occurrence

Has any judgement or payment of claim or settlement amount exceeded the limits of this coverage?

Yes

No

PREVIOUS PROFESSIONAL LIABILITY INSURANCE

CONFIDENTIAL INFORMATION:

Carrier:

Address:

Street

City

State

Zip

Policy Number (last 4 digits):

Original Effective Date:

Expiration Date:

(mm/dd/yy)

(mm/dd/yy)

Policy Limits:

Per Occurrence:

$

Aggregate:

$

Retroactive Date:

(mm/dd/yy)

What type of coverage do you have?

 Claims Made

 Occurrence

Has any judgement or payment of claim or settlement amount exceeded the limits of this coverage?

Yes

No

Check here if you have appended additional information for this section.

1.

Have any professional liability judgements ever been entered against you?

Yes

No

2.

Have any professional liability claim settlements ever been paid by you and/or paid on your behalf?

Yes

No

3.

Are there any currently pending professional liability suits, actions, and/or claims filed against you?

Yes

No

Have you ever been denied or voluntarily relinquished your professional liability insurance coverage, had your professional liability insurance coverage canceled or non-renewed, or had limits reduced?

Yes

No

Institution Name:

Address 1:

Street

City

State

Zip

Address 2:

Region

Country

Telephone Number:

(         )

Email:

Degree:

Year Graduated:

Dates attended:

From:

To:

(mm/yy)

(mm/yy)

If you are a graduate of a foreign medical school, are you certified by the Educational

Commission for Foreign Medical Graduates (ECFMG)?

 Yes

 No

Date Issued:

Serial Number for ECFMG

Were you the subject of any disciplinary action during your time at this

institution?

 Yes

 No

(Attach an explanation of a "yes" answer.)

If you attended more than one medical/professional school, please check here and

attach an explanation that duplicates the information requested above:

INTERNSHIP

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Dates attended:

From:

To:

(mm/yy)

(mm/yy)

Type of internship:

Rotating

Straight

If straight, please list specialty:

Did you successfully complete this program?

 Yes

 No

If "no", please attach

an explanation.

If more than one internship, please check here and attach additional information that duplicates

the information requested above:

Were you the subject of any disciplinary action during your time at this institution?

 Yes

 No

(Attach an explanation of a "yes" answer.)

FIRST RESIDENCY

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Dates attended:

From:

To:

(mm/yy)

(mm/yy)

Type of residency:

Did you successfully complete this program?

 Yes

 No

If "no", please attach an

explanation.

Were you the subject of any disciplinary action during your time at this institution?

 Yes

 No

(Attach an explanation of a "yes" answer.)

SECOND RESIDENCY

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Dates attended:

From

To:

(mm/yy)

(mm/yy)

Type of residency:

Did you successfully complete this program?

 Yes

 No

If "no", please attach an

explanation.

If more than two residencies, please check here and attach additional information that duplicates the information requested above:

Were you the subject of any disciplinary action during your time at this institution?

 Yes

 No

(Attach an explanation of a "yes" answer.)

FIRST FELLOWSHIP

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Dates attended:

From:

To:

(mm/yy)

(mm/yy)

Type of fellowship:

Did you successfully complete this program?

 Yes

 No

If "no", please attach an

explanation.

Were you the subject of any disciplinary action during your time at this institution?

 Yes

 No

(Attach an explanation of a "yes" answer.)

SECOND FELLOWSHIP

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Dates attended:

From:

To:

(mm/yy)

(mm/yy)

Type of fellowship:

Did you successfully complete this program?

 Yes

 No

If "no", please attach an

explanation.

Were you the subject of any disciplinary action during your time at this institution?

 Yes

 No

(Attach an explanation of a "yes" answer.)

If more than two fellowships, please check here and attach additional information that duplicates the information requested above:

TEACHING EXPERIENCE/FACULTY APPOINTMENT (MOST RECENT)

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Dates:

From:

To:

Rank/Position, if applicable:

(mm/yy)

(mm/yy)

Were you the subject of any disciplinary action during your time at this institution?

 Yes

 No

(Attach an explanation of a "yes" answer.)

TEACHING EXPERIENCE/FACULTY APPOINTMENT (PREVIOUS)

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Dates:

From:

To:

Rank/Position, if applicable:

(mm/yy)

(mm/yy)

Were you the subject of any disciplinary action during your time at this institution?

 Yes

 No

(Attach an explanation of a "yes" answer.)

If more than two teaching experiences/faculty appointments, check here and attach additional information that duplicates the information above:

MEMBERSHIP STATUS – USE FOR SECTIONS E, F AND G

Please use the following key to indicate Membership Status in Sections E (Hospital Membership – Current and Pending), F (Hospital Membership – Previous), and G (Ambulatory Surgical Treatment Center Practice) below:

A.

Active

F.

Active Provisional Staff

K.

Pending

B.

Courtesy

G.

Senior Staff

L.

Other (Specify)

C.

Consulting

H.

Associate

D.

Adjunct

I.

Provisional

E.

Suspended/

J.

Affiliate

Terminated/

Resigned

A.

Primary Hospital

Hospital Name:

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

To Present

From (mm/yy)

Department/Division:

Medical Staff Office Email:

Department Telephone #:

(          )

Any limitations in your area of specialty at this hospital?

B.

Other Hospital

Hospital Name:

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

To Present

From (mm/yy)

Department/Division:

Medical Staff Office Email:

Department Telephone #:

(          )

Any limitations in your area of specialty at this hospital?

C.

Other Hospital

Hospital Name:

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

To Present

From (mm/yy)

Department/Division:

Medical Staff Office Email:

Department Telephone #:

(          )

Any limitations in your area of specialty at this hospital?

Check here if you have appended additional information for this section

1.

Hospital Name

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

Department/Division:

Medical Staff Office Email:

Department Telephone #:

(          )

2.

Hospital Name

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

Department/Division:

Medical Staff Office Email:

Department Telephone #:

(          )

3.

Hospital Name

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

Department/Division:

Medical Staff Office Email:

Department Telephone #:

(          )

Check here if you have appended additional information for this section

A.

Primary Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

Email:

Telephone #:

(          )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

B.

Other Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

Email:

Telephone #:

(          )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

C.

Other Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

Email:

Telephone #:

(          )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

Check here if you have appended additional information for this section.

Current workplace:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To Present

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous workplace:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Check here if you have appended additional information for this section.

1.

Name:

Title:

Last

First

MI

Degree

Specialty:

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Relationship:

Years Known:

2.

Name:

Title:

Last

First

MI

Degree

Specialty:

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Relationship:

Years Known:

3.

Name:

Title:

Last

First

MI

Degree

Specialty:

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Email:

Relationship:

Years Known:

1.

Has your license to practice in any jurisdiction ever been denied, restricted, limited, suspended, revoked, canceled and/or subject to probation, either voluntarily or involuntarily, or has your application for a license ever been withdrawn?

Yes

No

2.

Have you ever been reprimanded and/or fined, been the subject of a complaint, and/or been notified in writing that you have been investigated as the possible subject of a criminal, civil or disciplinary action by any state or federal agency that licenses providers?

Yes

No

3.

Have you ever had your board certification rescinded or elected not to recertify, and/or failed to recertify?

Yes

No

4.

Have you ever been examined by a Certifying Board but failed to pass?

Yes

No

5.

Has any information pertaining to you, including malpractice judgements and/or disciplinary action, ever been reported to the National Practitioner Data Bank (NPDB) and/or any other practitioner data bank?

Yes

No

6.

Has your federal DEA number and/or state associated Controlled Substances License been restricted, limited, relinquished, suspended or revoked, either voluntarily or involuntarily, and/or have you ever been notified in writing that you are being investigated as the possible subject of a criminal or disciplinary action with respect to your DEA or controlled substance registration?

Yes

No

7.

Have your privileges at any hospital or other health care setting ever been suspended, revoked, voluntarily or involuntarily surrendered, reduced, restricted, not renewed, denied, or has probation ever been imposed?

Yes

No

8.

Has your membership at any hospital or other health care setting ever been suspended, revoked, voluntarily or involuntarily surrendered, not renewed, denied, or has probation even been imposed?

Yes

No

9.

Has your medical staff membership at any hospital or healthcare institution ever been voluntarily or involuntarily terminated?

Yes

No

10.

Have any disciplinary actions or proceedings been instituted against you and/or are any disciplinary actions or proceedings now pending with respect to your hospital or ASTC privileges and/or your license?

Yes

No

11.

Have you ever been reprimanded, censured, excluded, suspended and/or disqualified from participating in Medicare, Medicaid, CHAMPUS and/or any other governmental health-related programs, or voluntarily withdrawn to avoid an investigation relating to those programs?

Yes

No

12.

Have Medicare, Medicaid, CHAMPUS or PRO authorities, and/or any other third-party payors, brought charges against you for alleged inappropriate fees and/or quality-of-care issues?

Yes

No

13.

Have you ever withdrawn an application or any portion of an application for appointment or reappointment for clinical privileges or staff appointment or for a license or membership in an IPA, PHO, professional group or society, health care entity or health care plan prior to a final decision to avoid a professional review or an adverse decision?

Yes

No

14.

Has your authority to practice in any state been suspended, revoked, voluntarily or involuntarily surrendered, been subject to a consent order or stipulation order, not renewed, denied renewal, or has probation ever been imposed?

Yes

No

15.

Were you the subject of any disciplinary action(s) during your attendance at any academic or training institution, either during any formal education, training, or faculty appointments?

Yes

No

1.

Have you ever been charged with or convicted of a felony or misdemeanor (other than a minor traffic offense) in this or any other state or country and/or do you have any criminal charges pending other than minor traffic offenses in this State or any other state or country?

Yes

No

2.

Have you ever been the subject of a civil or criminal complaint or administrative action or been notified in writing that you are being investigated as the possible subject at a civil, criminal or administrative action regarding sexual misconduct, child abuse, domestic violence or elder abuse?

Yes

No

Do you currently have a physical illness or mental illness or disability that results in your inability to practice medicine with reasonable judgement, skill, and safety? (See Medical Practice Act – 225 ILCS 60/22(a))

Yes

No

CHEMICAL SUBSTANCES OR ALCOHOL USE DISORDER

If you answer "yes" to any questions in this section, please complete FORM F. Please make copies of FORM F, if needed, and complete one for each "yes" answer.

1.

Do you currently overuse and/or abuse alcohol or any controlled substances?

Yes

No

2.

If you use alcohol and/or chemical substances, does your use in any way impair and/or limit your ability to practice medicine with reasonable skill and safety?

Yes

No

3.

Are you currently participating in a supervised rehabilitation program and/or professional assistance program that monitors you for alcohol and/or substance use disorder?

Yes

No

INVESTMENTS

Apart from employment, in the last 5 years have you and/or a member of your family ever purchased or made an investment in (other than securities of a publicly traded company), or otherwise have a business interest in any clinical laboratory, diagnostic or testing center, hospital, surgical center, and/or other business dealing with the provision of ancillary health services, equipment or supplies?

Yes

No

If "yes", please provide explanation:

Primary Site

Group/Business Name

Building Name

Office Address – Number and Street – Suite

City

County

State

Zip

(          )

Main Telephone Number

Office Administrator –

Last

First

MI

(          )

Fax Number

E-Mail

(          )

(          )

Emergency Number

Answering Service

Specialty practiced at this site:

Is your practice restricted within your specialty (e.g., by age or type of patient)?

  Yes

  No

If "yes", describe the restrictions:

Briefly describe your practice at this location, including any special practice focus or

equipment:

Are you currently accepting new patients at this location?

  Yes

  No

If "yes", describe any 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:

Please provide the business hours, including days of the week and hours of operation:

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

New Patient

Existing Patient

Emergency Care

Urgent Care

Symptomatic Care (e.g., sore throat)

Routine Visits (e.g., blood pressure check)

Preventative Routine Care (e.g., school or annual physical)

Please provide the following regarding your practice at this site:

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:

Please check all procedures you perform at this site:

  Age-appropriate immunizations

  EKG

  Drawing blood

  Tympanometry/audiometry screening

  X-rays

  Minor surgery

  Pulmonary function studies

  Flexible sigmoidoscopy

  Laceration repair

  Office gynecology (routine pelvic/PAP)

  Asthma treatment

  Allergy skin testing

  Osteopathic/chiropractic manipulation

  IV hydration/ treatment

  Physical therapy

  Acupuncture

  Pathology

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:

Is this practice site handicapped accessible (check all that apply)?

  Building

  Parking

  Wheelchair

  Restroom

Does this site employ paraprofessionals for direct patient care?

  Yes

  No

If "yes", is supervision always provided on premises during paraprofessional's direct patient

care?

  Yes

  No

Do the paraprofessionals bill under any of your Tax ID Numbers?

  Yes

  No

CONFIDENTIAL INFORMATION:  If "yes", list Tax ID Numbers used:

Lab service at this site:

  Yes

  No

If "yes", check whether:

  Primary

  Secondary

  Tertiary

CLIA Waiver:

  Yes

  No

CLIA Expiration Date:

Please provide the following information about physicians/practitioners who provide coverage for patients enrolled at this site when you are not available.

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Please provide the following information about physicians/practitioners who practice in this office:

Name:

Specialty:

Last

First

MI

Name:

Specialty:

Last

First

MI

Name:

Specialty:

Last

First

MI

Business Arrangement #1

Name of Business Arrangement on SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site:

(       )

Business Arrangement #2

Name of Business Arrangement on SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site:

(       )

Business Arrangement #3

Name of Business Arrangement on SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site:

(       )

Business Arrangement #4

Name of Business Arrangement on SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site:

(       )

Site

Group/Business Name

Building Name

Office Address – Number and Street – Suite

City

County

State

Zip

(        )

Main Telephone Number

Office Administrator –

Last

First

MI

(        )

Fax Number

E-Mail

(        )

(        )

Emergency Number

Answering Service

Specialty practiced at this site:

Is your practice restricted within your specialty (e.g., by age or type of patient)?

  Yes

  No

If "yes", describe the restrictions:

Briefly describe your practice at this location, including any special practice focus or

equipment:

Are you currently accepting new patients at this location?

  Yes

  No

If "yes", describe any 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?

Please provide the business hours, including days of the week and hours of operation:

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

New Patient

Existing Patient

Emergency Care

Urgent Care

Symptomatic Care (e.g., sore throat)

Routine Visits (e.g., blood pressure check)

Preventative Routine Care (e.g., school or annual physical)

Please provide the following regarding your practice at this site:

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:

Please check all procedures you perform at this site:

  Age-appropriate immunizations

  EKG

  Drawing blood

  Tympanometry/audiometry screening

  X-rays

  Minor surgery

  Pulmonary function studies

  Flexible sigmoidoscopy

  Laceration repair

  Office gynecology (routine pelvic/PAP)

  Asthma treatment

  Allergy skin testing

  Osteopathic/chiropractic manipulation

  IV hydration/ treatment

  Physical therapy

  Acupuncture

  Pathology

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:

Is this practice site handicapped accessible (check all that apply)?

  Building

  Parking

  Wheelchair

  Restroom

Does this site employ paraprofessionals for direct patient care?

  Yes

  No

If "yes", is supervision always provided on premises during paraprofessional's direct patient

care?

  Yes

  No

Do the paraprofessionals bill under any of your Tax ID Numbers?

  Yes

  No

CONFIDENTIAL INFORMATION:  If "yes", list Tax ID Numbers used:

Lab service at this site:

  Yes

  No

If "yes", check whether:

  Primary

  Secondary

  Tertiary

CLIA Waiver:

  Yes

  No

CLIA Expiration Date:

Please provide the following information about physicians/practitioners who provide coverage for patients enrolled at this site when you are not available.

Name:

Specialty:

Last

First

MI

Degree

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION:   Tax ID#:

Name:

Specialty:

Last

First

MI

Degree

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Specialty:

Last

First

MI

Degree

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Specialty:

Last

First

MI

Degree

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

 Days

 Nights

 Weekends

 Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Please provide the following information about physicians/practitioners who practice in this office:

Name

Specialty:

Last

First

MI

Name

Specialty:

Last

First

MI

Name

Specialty:

Last

First

MI

Business Arrangement #1

Site #:

Name of Business Arrangement on SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site:

(       )

Business Arrangement #2

Site #:

Name of Business Arrangement on SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site:

(       )

Business Arrangement #3

Site #:

Name of Business Arrangement on SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site:

(       )

Business Arrangement #4

Site #:

Name of Business Arrangement on SS4 or W-9 Form:

Type of Arrangement (e.g., solo or group practice, IPA, PHO):

CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:

Billing Address, if Different from Primary Site:

Telephone Number, if Different from Primary Site:

(       )

Applicant Name:

Last

First

MI

Indicate the number of ONE of the questions in Section J to which you answered "yes":

Question Number:

A.

Describe the circumstances surrounding this occurrence. Please include the date of the occurrence.

B.

Provide an explanation of any actions taken. Please include the date the action was taken.

C.

Provide the current status of the issue.

D.

If known:

Contact:

Department/Committee:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Signature:

Date:

Applicant Name:

Last

First

MI

A.

Plaintiff's Name:

Last

First

MI

If court case, State/jurisdiction, Case Name & Case Number:

B.

Your Involvement in the Care (Attending, Consulting, Etc.):

C.

Your Status in the Case (Sole Defendant, Co-Defendant, Ownership Interest in

Provider Practice Named in Suit, Etc.)

D.

Allegations, including Patient Outcome, If Available:

E.

Date of Incident (mm/yy)

F.

Date Filed (mm/yy)

G.

Date Case Closed (mm/yy):

Case Resolution:

Dismissed

Judgement

Arbitration

Other

Settlement Out of Court

Pending

Mediation

H.

Amount Paid on Your Behalf (if any): $

I.

Professional Liability Insurer Name (if one was involved):

J.

Insurer Telephone Number:

(        )

K.

Policy Number (last 4 digits):

L.

Insurer Address (Street, City, State, Zip Code):

Signature:

Date: