Default Page Physician License Renewal Physician Name This field is required This field needs to be a valid value If the information you will be asked to give is not truthful, disciplinary action may be taken against your license. Dr. you affirm that the information you are about to give or answer is true & correct? 1 = Yes 2 = No This field is required Do you have an address change from your Credential Address below to a location outside of the United States? NOTE: if your Credential Address below already shows an address outside of the United States, then answer “No” 1 = Yes 2 = No This field is required Has your name legally changed since your most recent renewal or your initial application? 1 = Yes 2 = No This field is required Would you like to place your licenses on Inactive status? 1 = Yes 2 = No This field is required Have you fully complied with the continuing education requirement for the renewal of your license? NOTE: CE is not required for the first renewal of this license. If this is your first renewal, please answer “Yes” to this question. 1 = Yes 2 = No This field is required Are you more than 30 days delinquent in complying with a Child Support Order? NOTE: If you are not subject to a Child Support Order, then answer “No”. 1 = Yes 2 = No This field is required Pursuant to Public Act 91-0244, effective January 1, 2000, if you have reason to believe that an adult 60 years of age or older who resides in a domestic living situation who, because of dysfunction is unable ot seek assistance for himself or herself has, within the previous 12 months been subject to abuse, neglect or financial exploitation, the mandated reporter shall, within 24 hours after developing such belief, report this suspicion to the Department on Aging at 1-800-252-8966. Public Act 91-0244 also requires that if you have reasonable cause to believe a child known to you in your professional capacity may be an abused or neglected child you are required to report such possible neglect or abuse to the Department of Children & Family Services at 1-800-25abuse. Have you read & understood the above statements regarding child & elder abuse reporting? 1 = Yes 2 = No This field is required Are you currently charged with or have you been convicted of a criminal act that requires registration under the Sex Offender Registration Act? 1 = Yes 2 = No This field is required Are you currently charged with or have you been convicted of a criminal battery against any patient in the course of patient care or treatment, including any offense based on sexual conduct or sexual penetration? 1 = Yes 2 = No This field is required Are you required, as part of a criminal sentence, to register under the Sex Offender Registration Act? 1 = Yes 2 = No This field is required Are you currently charged with or have you been convicted of a forcible felony? 1 = Yes 2 = No This field is required Since your initial application or most recent renewal, whichever is more recent, or if not previously disclosed, have you been disciplined (including but not limited ot restricted, suspended, or terminated) by any hospital, health care entity, or post-graduate clinical training program? Please provide a detailed explanation as to why you answered the previous question as "YES" and send all official records related to this action to Cathy Wingler at cwingler@christieclinic.com. 1 = Yes 2 = No This field is required Since your initial application or most recent renewal, whichever is more recent, or if not previously disclosed, have you resigned in lieu of discipline or while under investigation that could lead to any restriction, suspension, or termination by any hospital, health care entity, or post-graduate clinical training program? Please provide a detailed explanation as to why you answered the previous question as "YES" and send all official records related to this action to Cathy Wingler at cwingler@christieclinic.com. 1 = Yes 2 = No This field is required Since your initial application or most recent renewal, whichever is more recent, or if not previously disclosed, have you had staff membership or privileges in any hospital or health care facility involuntarily reduced, limited, placed on probation, relinquished, denied, revoked, or suspended? You must answer yes if any of these actions are currently pending or if you have withdrawn or failed to proceed with an application for staff membership or privileges. Please provide a detailed explanation as to why you answered the previous question as "YES" and send all official records related to this action to Cathy Wingler at cwingler@christieclinic.com. 1 = Yes 2 = No This field is required Since your initial application or most recent renewal, whichever is more recent, or if not previously disclosed, has your provider status been restricted, suspended, or terminated by any insurance carrier, including but not limited to Medicare, Medicaid, Tricare, or any private carrier? Please provide a detailed explanation as to why you answered the previous question as "YES" and send all official records related to this action to Cathy Wingler at cwingler@christieclinic.com. 1 = Yes 2 = No This field is required Since your initial application or most recent renewal, whichever is more recent, or if not previously disclosed, have you voluntarily surrendered a license to practice your profession in any state, country, or U.S. federal jurisdiction? This does not include allowing your license to expire solely due to non-payment of the renewal fee. Please provide a detailed explanation as to why you answered the previous question as "YES" and send all official records related to this action to Cathy Wingler at cwingler@christieclinic.com. 1 = Yes 2 = No This field is required Since your initial application or most recent renewal, whichever is more recent, or if not previously disclosed, have you withdrawn an application for a license to practice your profession or any temporary/resident licenses in any other state, country, or U.S. federal jurisdiction? Please provide a detailed explanation as to why you answered the previous question as "YES" and send all official records related to this action to Cathy Wingler at cwingler@christieclinic.com. 1 = Yes 2 = No This field is required Since your initial application or most recent renewal, whichever is more recent, or if not previously disclosed, have you been admonished, reprimanded, censured, and/or disciplined in any way by any professional or medical society or association, or by any non-licensing governmental agency including, but not limited to any governmental assistance agency? (Disciplinary actions include, but are not limited to, any allegation currently pending.) Disclose any stipulation to informal disposition in response to this question. Please provide a detailed explanation as to why you answered the previous question as "YES" and send all official records related to this action to Cathy Wingler at cwingler@christieclinic.com. 1 = Yes 2 = No This field is required Since your initial application or most recent renewal, whichever is more recent, or if not previously disclosed, have you been convicted of or pled guilty or nolo contendere to any criminal offense in any state court or in federal court? Please do not give details on minor traffic charges but do include information relating to Driving While Intoxicated (DWI) charges. Please provide a detailed explanation as to why you answered the previous question as "YES" and send all official records related to this action to Cathy Wingler at cwingler@christieclinic.com. In general, a criminal conviction by itself does not usually result in denial of licensure. 1 = Yes 2 = No This field is required Since your initial application or most recent renewal, whichever is more recent, or if not previously disclosed, have you been convicted of or pled guilty or nolo contendere to a felony offense in any state court or in federal court? In general, a felony conviction by itself does not usually result in denial of licensure. 1 = Yes 2 = No This field is required Since your initial application or most recent renewal, whichever is more recent, or if not previously disclosed, have you been issued a Certificate of Relief from Disabilities by the Prisoner Review Board? If YES, attach a copy of your Certificate of Relief. 1 = Yes 2 = No This field is required Since your initial application or most recent renewal, whichever is more recent, or if not previously disclosed, do you now have any disease or condition that presently limits your ability to perform the essential functions of your profession, including any disease or condition generally regarded as chronic by the medical community, i.e., (1) mental or emotional disease or condition: (2) alcohol or other substance abuse: (3) physical disease or condition? Please provide a detailed explanation as to why you answered the previous question as "YES" and send all official records related to this action to Cathy Wingler at cwingler@christieclinic.com. 1 = Yes 2 = No This field is required Since your initial application or most recent renewal, whichever is more recent, or if not previously disclosed, have you been denied a professional license or permit, or privilege of taking an examination, or had a professional license or permit disciplined in any way by any licensing authority in Illinois or elsewhere? Please provide a detailed explanation as to why you answered the previous question as "YES" and send all official records related to this action to Cathy Wingler at cwingler@christieclinic.com. 1 = Yes 2 = No This field is required Since your initial application or most recent renewal, whichever is more recent, or if not previously disclosed, have you been discharged other than honorably from the armed service or from a city, county, state, or federal position? Please provide a detailed explanation as to why you answered the previous question as "YES" and send all official records related to this action to Cathy Wingler at cwingler@christieclinic.com. 1 = Yes 2 = No This field is required A prescription for a substance classified in Schedule II, III, IV, or V must be sent electronically, in accordance with Section 316 of the Illinois Controlled Substances Act (720 ILCS 570/). However, a prescriber shall not be required to issue prescription electronically if the prescriber certifies to the IDFPR that he or she will not ussie more than 150 prescriptions during a 12-month period or demonstrates economic hardship in accordance with Section 311.6. Prescription or controlled substances in oral & written form shall be included in determining whether the prescriber will reach the limit of 150 prescriptions. Do you qualify for a low volume waiver under 720 ILCS 570/311.6? 1 = Yes 2 = No This field is required Do you qualify for a hardship waiver from the Centers for Medicare for Electronic Prescribing for Controlled Substances? 1 = Yes 2 = No This field is required Please Note: Only one registration is required to prescribe controlled substances in Illinois. A separate registration is required for each place of professional practice or business where controlled substances are stored or located. Have you read & understood the above statements regarding required registration? 1 = Yes 2 = No This field is required Have you completed 1 hour of Continuing Education on safe opioid prescribing as required for the renewal of your Controlled Substance license? 1 = Yes 2 = No This field is required Nice try spambot