Name in Full:

Office Address:

Office Telephone:

Clinical Specialty:

1.) How long have you been established at your current office location?

Office Address:

If the office is to be established in the future, state the date you anticipate first holding office hours:

How many patients are seen in your office per month?

Are you currently accepting new patients?

2.) Are you or will you be a member of or associated with a practice group?

Please identify the practice group and other physicians/practitioners in the group?

3.) In what specialties are you or have you been Board Certified and year of certification?

4.) Have you ever been denied privileges at a hospital?

5.) Have you ever been disciplined, lost privileges or voluntary relinquished privileges?

6.) Has action limiting, restricting or withdrawing your license ever occurred?

7.) Are you employed by or associated with a Hospital, Hospital System, Health Maintenance Organization or similar organization to care for and treat patients?

If your response is in the affirmative, please state the name and address of the Hospital et al. by whom you are employed or with which you are associated:

8.) Expressed as a percentage, state the extent of your practice you anticipate at hospitals?

At which hospitals do you currently have staff privileges and percentage of admissions to each?

9.) With whom do you share hospital and skilled nursing facility coverage, if applicable?

How often do you provide coverage?

10.) Do you see patients regularly at a skilled nursing facility?

If your response is in the affirmative please state the name and address of those facilities:

You will need to provide a copy of your CAQH State of Illinois application summary. 
Please state if you have and can produce copies of:
Current license(s) to practice medicine
Current Federal Narcotics License (DEA Number will be requested)
Proof of professional libaility insurance coverage including the effective date, with limits of coverage of not less than $1 Million/$3 Million
Proof of successful completion of post-graduate residency training program
Certificate from a Specialty Board or proof of your registration to sit for the examination
Medical School Diploma or other professional diploma

Contact Information: Please provide your contact information for questions related to the completion of this application:

Contact Name:

Contact Email:

Contact Telephone:

Contact Fax Number:

Electronic Signature: By submitting this form, you acknowledge that the information is accurate to the best of your understanding and that the content will be reviewed by SIHCA staff before further action is taken.  If you agree to these terms, please fill in your full name and credentials in the box below, then click Submit.