Get Schedule E - Medical Director Or Physician (pdf) - Illinois ... - Dhs State Il

This guide provides comprehensive instructions on how to fill out the Schedule E - Medical Director Or Physician form for Illinois online. Whether you are a new user or familiar with digital document management, this step-by-step approach will help ensure your submission is accurate and complete.

Follow the steps to fill out the Schedule E form accurately and efficiently.

1. Press the ‘Get Form’ button to obtain the document and open it in your preferred editor.
2. Begin filling out the form by entering the facility name where you are employed. Ensure that this is the official name of the facility.
3. Enter your full name in the designated field. Accuracy is crucial, as this information will be used for identification purposes.
4. Specify your sex in the appropriate section, ensuring this aligns with your identification documentation.
5. Provide your social security number in the field provided for verification purposes. Remember that disclosure is voluntary.
6. Indicate your position at the facility, such as ‘Medical Director’ or ‘Physician’.
7. Fill in your date of birth and place of birth. This information helps establish your identity.
8. Complete your residential address by including the street address, city, state, and zip code.
9. Provide your telephone number in the specified format.
10. List your professional registration numbers, including your Illinois Professional Medical License Number, Illinois Controlled Substances License Number, and Drug Enforcement Administration Registration Number.
11. Indicate whether your registration is in good standing by selecting ‘Yes’ or ‘No.’
12. If applicable, indicate if you are engaged in other professional practice and specify where.
13. Summarize your previous associations with alcoholism and substance abuse programs, including names, locations, and dates of service.
14. Answer the questions regarding any felony convictions, suspension of federal registration, and whether you have read the Department of Human Services Rule Part 2060.
15. Sign the form and provide the date of signature to validate your submission.
16. Once all fields are completed, you can save changes, download, print, or share the finalized document as needed.

Complete your Schedule E form online today to ensure compliance and proper certification.