Who needs a Health Care Professional Recredentialing and Business data gathering form?
This form is used by health care professionals in the state of Illinois for the recredentialing purposes. It is collected from health care professionals by hospitals, health care entities, and health care plans in order to credential such professionals.
What is the purpose of the Gathering form?
The form is completed to provide information about the health care professional, such as personal information, professional details, work experience, etc. This data is used by the entity or entities that conduct the credentialing.
What documents must accompany the Gathering form?
This form is usually accompanied by a CV, professional licenses, Federal DEA license, state controlled substance license, professional liability insurance or declaration of insurance, CLIA certificate, W-9 form. The health care specialist may need to attach other forms if applicable.
When is the Gathering form due?
This form should be submitted to the appropriate medical entity when there is a need. The form requires a lot of information from the applicant and it could take up to several hours to complete it.
What information should be provided in the form?
The form is divided into main parts: Practice and Professional information and Business information.
The applicant has to fill in the following sections:
- General information
- Professional information
- Hospital membership (current and pending)
- Ambulatory surgery center practice
- Work history
- Medical education
- Professional history (liability actions, liability insurance, criminal actions, medical condition, chemical substances or alcohol abuse, investments)
- Primary and additional site information
The applicant also has to affirm and date the form in the beginning.
What do I do with the form after its completion?
The form is submitted to the hospital, health care entity, or health care plan. Some parts of the form should be duplicated if there is a need.