|The Health Care Credentials and Data Collection Act requires
uniform forms to be utilized in order to collect the credentials data commonly
requested by health care entities and health care plans for purposes of
credentialing and recredentialing.
Following are Word and PDF versions of the forms required for use by the Health Care Professional Credentialing and Data Collection Act (410 ILCS 517).
These forms are for use with the entity or entities that are conducting the credentialing. DO NOT SEND COMPLETED FORMS TO THE STATE. Please contact the health care plan, health care entity or hospital that is reviewing your credentials for instructions on where to send this form and any other information it may require in order to complete the credentialing process.
Health Care Professional Credentialing and Business Data Gathering Form
(Word Document, 748K) (Adobe Acrobat PDF, 122K)
Health Care Professional Recredentialing and Business Data Gathering Form
(Word Document, 493K) (Adobe Acrobat PDF, 141K)
(Recredentialing Form A Adverse and Other Actions, 42K)
(Recredentialing Form B Professional Liability Actions, 45K)
(Recredentialing Form C Liability Insurance, 40K)
(Recredentialing Form D Criminal Actions, 45K)
(Recredentialing Form E Medical Condition, 42K)
(Recredentialing Form F Chemical Substances or Alcohol Abuse, 493K)
Health Care Professional Update Data Gathering Form
(Word Document, 47K) (Adobe Acrobat PDF, 28K)
The content for these forms was published in the Illinois Register on September 7, 2001 and the administrative rules can be found at 77 IL Admin Code 965. Use of these forms will go into effect January 1, 2002. The forms adopted in this Part cannot be altered in structure. Nothing in the Act or rules requires a health care entity, health care plan or hospital to seek all of the credentials data that may be provided in the mandated credentials data gathering forms. The extent to which a health care entity, health care plan or hospital requires a health care professional to complete the applicable sections of the forms is within the discretion of the health care entity, health care plan or hospital. However, no health care entity, plan or hospital may reject or deny a form that includes more information than the requirements of the individual entity, plan or hospital.
Beginning January 1, 2002, each health care entity, hospital or health care plan that employs, contracts with, or allows health care professionals to provide medical or health care services and requires health care professionals to be credentialed or recredentialed shall for purposes of collecting credentials data only require the forms established by this Act and rule. A health care entity includes ASTC's, home health agencies, long term care facilities and any other entity licensed or certified to provide health care that credentials.
of Public Health
535 West Jefferson Street
Springfield, Illinois 62761
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