Initial Credentialing Process
Here is the CCPA Initial Credentialing Checklist for you to use. This checklist was created to give you a detailed list of items needed to submit to CCPA for initial credentialing.
However, there are eligibility requirements a physician must meet before becoming a member of CCPA. Review the
membership eligibility page for details.
Physicians can also receive directions to the initial credentialing process by emailing email@example.com. Once the request has been received, CCPA’s members relations specialist
will email to the requesters two PDF files and information on what is needed to begin the request for application process for the Ann & Robert H. Lurie Children’s Hospital of Chicago Medical Staff Office.
CCPA Initial Credentialing Important Items
- Complete EACH page of the “STATE OF ILLINOIS Health Care Professional Credentialing and Business Data Gathering Form.”
Please ensure that all gaps in educational training and/or work history that are greater than 30 days, are explained in a separate attachment and included with your application. Please ensure
that your dated signature on page two (2) of the application is current at the time your application is submitted to CCPA. CCPA will not accept an application that has been dated 30 days or more prior to the date the application is submitted to CCPA.
- All references on page eighteen (18) of your application must be physicians. References may not belong to your current practice group. If you are not a part of or joining a current CCPA practice, at least one of your references must be a member of CCPA and/or
on staff at Ann & Robert H. Lurie Children’s Hospital of Chicago (please contact CCPA if you are unable to provide a reference that meets this requirement). CCPA will contact all three references listed on your application and request
a letter of recommendation from everyone on your behalf. To avoid delays, please contact your references before listing them on your application to ensure that they are willing to provide CCPA with a letter of recommendation for you.
Please be sure that all reference contact information listed on your application is accurate and complete.
- Please see the cover page of the State of Illinois application for more detailed instructions regarding completing your State of Illinois Healthcare Professional Credentialing and Business Data Gathering Form.
Support Documents Needed
- All Current Professional License(s) [i.e., State Medical License(s), etc.]
- Current Federal Drug Enforcement Administration Certificate
- Current State Controlled Substance Certificate(s)
- Current Certificate of Insurance
- Educational Commission for Foreign Medical Graduates Certificate (if applicable)
- Copies of Diploma(s), Residency Certificate(s), Fellowship Certificate(s) as applicable
- Current Curriculum Vitae
- CCPA Forms*
- CCPA Attestation and Consent for Release of Information/Release from Liability* (CCPA will not accept your application if this form has been dated 30 days or more prior to the date the application is received by CCPA).
*Please click here
to access all CCPA forms listed above.
To view the CCPA initial credentialing process in more detail, please review the CCPA Credentialing Policies and Procedures.