Get Il Health Care Professional Recredentialing And Data Gathering Form

Filling out the IL Health Care Professional Recredentialing and Data Gathering Form online is a crucial step for health care professionals seeking recredentialing. This guide will provide you with clear and detailed instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in an online editor.
2. Complete Chapter A: Practice and Professional Information. Begin by entering your personal details such as name, previous names, birth date, and citizenship status.
3. Fill out Section B: Professional Information. Include your Illinois Professional License Number and list current professional licenses in other states, indicating any limitations.
4. Provide your current Federal DEA License Number and other relevant certifications, checking if additional information needs to be appended.
5. Complete Section C: Hospital Membership - Current and Pending by listing hospitals where you hold or applied for privileges.
6. In Section D: Ambulatory Surgery Center Practice, enter details of any ambulatory surgery centers you've been affiliated with.
7. List your work history chronologically in Section E, detailing your previous employment for the last four years.
8. Update your medical education and clinical training in Section F, providing information for any relevant educational engagements.
9. Answer questions in Section G regarding your professional history, ensuring accuracy and honesty.
10. Fill out Chapter B: Business Information, including primary and additional site information where you practice.
11. Review all entries for accuracy, save your changes, and share, download, or print the form as needed.

Start completing your documents online today and ensure your recredentialing process is smooth and successful.