STATE OF ILLINOIS Health Care Professional Credentialing and Business Data Gathering Form The Health Care Professional Credentials Data Collection Act [410 ILCS 517] requires that this form be collected from health care - Multiplan - Document - PDFSEARCH.IO

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	STATE OF ILLINOIS Health Care Professional Credentialing and Business Data Gathering Form The Health Care Professional Credentials Data Collection Act [410 ILCS 517] requires that this form be collected from health care Add to Reading List Document Date: 2013-09-20 10:24:48 Open Document File Size: 198,38 KB Share Result on Facebook Company License Unlimited / CONFIDENTIAL INFORMATION License Unlimited / / Country United States / / Facility Print Name Date PLEASE BE ADVISED THAT EACH HOSPITAL / / IndustryTerm liability insurance carriers / / Organization Educational Commission for Foreign Medical Graduates / Certifying Board / Medicare / / Person Chapter / / Position Program Director / AND PROFESSIONAL INFORMATION SECTION A. GENERAL INFORMATION Name / Chair Department / / Technology X-Ray / / SocialTag Credentialing Health care Doctor of Osteopathic Medicine Credential Medicine Health Time and date

STATE OF ILLINOIS Health Care Professional Credentialing and Business Data Gathering Form The Health Care Professional Credentials Data Collection Act [410 ILCS 517] requires that this form be collected from health care Add to Reading List