As set forth in the Illinois Medical Practice Act (“Act”), physicians are required to complete a report for the following: a. Adverse final action taken against you by any of the following:
another licensing jurisdiction (any other state or any territory of the United States or any foreign state or country),
peer review body,
health care institution,
professional society or association related to practice under the Act,
law enforcement agency,
court for acts or conduct similar to acts or conduct which would constitute grounds for action as defined in the Act, or
state or federal agency that restricts or prohibits you from providing services to the agency’s participants.
Surrender of a license or authorization to practice as a medical doctor, a doctor of osteopathy, a doctor of osteopathic medicine, or doctor of chiropractic in another state or jurisdiction, or surrender of membership on any medical staff or in any medical or professional association or society, while under disciplinary investigation by any of those authorities or bodies, for acts or conduct similar to acts or conduct which would constitute grounds for action as defined in the Act; or b. c.
2. Email complete signed forms to FPR.MedicalAdverse@Illinois.gov within 60 days. Adverse judgment, settlement, or award arising from a liability claim related to acts or conduct similar to acts or conduct which would constitute grounds for action as defined in the Act.
The following is required:
Physician Name: Physician License No.: Physician Email: Physician Phone No.: Physician Address: (City, State, Zip Code) check if address changed PHYSICIAN ADVERSE ACTION INFORMATION Date of Occurrence: Description: Please use additional pages if needed and attach all relevant documentation (including, but not limited to a copy of an adverse final action taken against you).