To Practitioners applying for Participation with HMO, PPO and Point of Service product:
Submit this attestation, signed & dated, along with State of Illinois Health Care
Professional Credentialing/ Recredentialing and Business Data Gathering Form.
ATTESTATION FOR PROVIDER CREDENTIALING
I authorize Blue Cross and Blue Shield of Illinois (BCBSIL) to consult with hospital administrators, members of hospital
medical staffs, professional liability carriers, managed care organizations, the National Practitioner Data Bank, and other
persons or entities to obtain information concerning my qualifications, including, but not limited to, my professional
qualifications, background, abilities, competence and my practice history.
I consent to the release to BCBSIL of any and all information that may be relevant to an evaluation of my qualifications,
including information about disciplinary actions and information that might otherwise be considered confidential or
privileged.
I authorize BCBSIL to release this information, as well as quality assurance data relating to me, to medical groups,
independent practice associations and similar entities contracting with BCBSIL and as authorized under state and federal
law or regulation.
I release BCBSIL and any and all persons or entities providing information about me to BCBSIL from any and all liability
connected with or arising from the release of such information, provided that such party(ies) was acting in good faith and
without malice in evaluating my application and any decisions related to my application or credentialing status.
I understand that I have the burden of providing adequate information to BCBSIL to demonstrate my qualifications. I
understand and agree that any misstatement or material omission in this application will constitute grounds for rejection of
my application or summary dismissal as a participating provider in any and all managed care networks contracting with
BCBSIL.
If any material changes occur in the information I have provided in this application making such information no longer
correct and complete or affecting my professional status, I understand and agree that it is my obligation to notify BCBSIL
or the appropriate subsidiary or affiliate within ten (10) days of said occurrence. Failure to comply with this obligation may
constitute grounds for rejection of my application or summary dismissal as a participating provider in any and all managed
care networks contracting with BCBSIL.
I agree that a photocopy of this document with my signature may be accepted by any entity from which such information
is sought, with the same authority as the original.
I attest that the information contained in this application is correct and complete.
__________________________________________ ____________________________________
Physician Signature Date
__________________________________________ ____________________________________
Physician Name (Please Print) License Number
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 03362.0213
Corporate Credentialing, 23rd Floor
300 E. Randolph St.
Chicago, Illinois 60601-5099
