Get Hospital /ancillary Provider Credentialing Application - Illinicare

This guide provides step-by-step instructions for completing the Hospital /ancillary Provider Credentialing Application - Illinicare online. Ensure that all required fields are filled and documents are attached for a successful submission.

Follow the steps to fill out the application accurately and completely.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Begin by filling out the ownership and management section. Provide names and titles of key individuals such as the president, vice president, CFO, and medical director.
3. In the legal information section, ensure you include the entity's legal name, federal tax ID numbers, and Medicaid numbers. Make sure to also list the Illinois State License number.
4. Fill in the facility information section, including facility type and address. Indicate affiliation with other healthcare organizations if applicable.
5. Complete the diagnostic imaging section by answering questions about procedures, machinery, and compliance with state laws.
6. Address the laboratory section by confirming compliance with the Clinical Laboratory Improvement Amendments of 1988 (CLIA).
7. Provide insurance coverage details, listing current professional liability and worker's compensation insurance carriers along with coverage amounts and dates.
8. Fill out the accreditation and certification section, providing copies of necessary documents and accrediting bodies as applicable.
9. Review and answer all questions under the sanctions section carefully. Any 'yes' answers will require detailed explanations on a separate sheet.
10. Read through the provider responsibility statement, ensuring understanding of obligations regarding practitioner qualifications and notify the IlliniCare Health Plan of updates.
11. Complete the statement of application by signing and dating the document. Ensure that a person authorized to sign for the provider completes this section.
12. Attach all necessary supplemental documents as listed, including licenses and insurances, before submission.
13. Save the completed application, ensuring that all sections are filled out correctly. You may then download, print, or share the form as needed.

Take the first step towards your credentialing process by completing the Hospital /ancillary Provider Credentialing Application online today.