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Illinois Department of Financial and Professional Regulation TEM-
Division of Professional Regulation
HEALTH CARE TEMPORARY PRACTICE APPLICATION COV19
DIRECTIONS: Only Physicians (MD), Licensed Practical Nurses (LPN), Registered Nurses (RN), Advanced Practice
Registered Nurses (APRN), Physician Assistants (PA), Respiratory Care Practitioner (RCP), Pharmacists (PH), Dietitian
Nutritionists (DN), Clinical Professional Counselors (LCPC), Professional Counselors (LPC), Clinical Psychologists (CP),
Physical Therapists (PT), Physical Therapist Assistants (PTA), Clinical Social Workers (LCSW), Social Workers (LSW),
Occupational Therapists (OT), & Occupational Therapist Assistants (OTA) may use this form to apply for a Temporary
Practice Permit, which will be valid through May 31, 2022 or until the expiration of the Gubernatorial COVID-19 Disaster
Proclamation. Physician applicants ONLY are required to complete the personal history questions on this form.
PLEASE CHECK THE BOX THAT INDICATES YOUR OUT-OF-STATE LICENSE:
Physician LPN, RN, APRN, PA, RCP, PH, DN, LCPC, LPC, CP, PT, PTA, LCSW, LSW, OT, OTA
APPLICANT IDENTIFYING INFORMATION
First Name: ________________________________ Last Name: ___________________________________________
City: ________________________________________ State: ____________________ Zip: ____________________
Phone Number: __________________________ Email Address: ___________________________________________
SSN: ______________ Date of Birth: ____________________ Profession Name:______________________________
License Number: ___________________ License State: _______________ License Expiry Date:__________________
PURSUANT TO 20ILCS 2105-165(a), THE DEPARTMENT REQUIRES THE DISCLOSURE OF INFORMATION
REGARDING CONVICTIONS PERTAINING TO CERTAIN OFFENSES FOR THIS PROFESSION. YOU MUST
RESPOND TO EACH OF THE FOLLOWING QUESTIONS:
1) Are you currently charged with or have you been convicted of a criminal act that requires registration under the Sex
Offender Registration Act? NO YES
2) 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? NO YES
3) Are you required, as part of a criminal sentence, to register under the Sex Offender Registration Act
4) Are you currently charged with or have you been convicted of a forcible felony? NO YES
PERSONAL HISTORY FOR PHYSICIANS ONLY: COMPLETION OF THE QUESTIONS BELOW IS NECESSARY TO
ACCOMPLISH THE REQUIREMENTS OUTLINED IN 225 ILCS 60 (MEDICAL PRACTICE ACT) OF THE ILLINOIS
COMPILED STATUTES. DISCLOSURE OF THIS INFORMATION IS VOLUNTARY. HOWEVER, FAILURE TO COMPLY
MAY RESULT IN THIS APPLICATION NOT BEING PROCESSED.
1) Have you ever been disciplined (including but not limited to restricted, suspended, or terminated) by any hospital or
health care entity? If yes, attach a separate sheet with complete and accurate explanation. NO YES
2) Have you ever resigned in lieu of discipline or while under investigation that could lead to any restriction, suspension,
or termination by any hospital or health care entity? If yes, attach a separate sheet with complete and accurate
explanation. NO YES
3) Have you ever been denied staff membership or privileges in any hospital or health care facility or had such
membership or privileges 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 privileges/memberships. If yes, attach a separate sheet with complete and accurate
explanation AND request the hospital or health care facility to submit a report directly to the Department regarding the
action. NO YES
4) Has your provider status ever been restricted, suspended or terminated by any insurance carrier, including but not
limited to Medicare, Medicaid, Tricare or any private carrier? If yes, attach a separate sheet with complete and accurate
explanation. NO YES
5) Have you ever voluntarily surrendered a license to practice medicine 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. If
yes, attach a separate sheet with complete and accurate explanation AND request all official disciplinary documents
including initial complaint, stipulations, orders, agreements or reprimands be sent directly to the Department.
6) Have you ever withdrawn an application for a license to practice medicine or any temporary/resident license in any
other state, country, or U.S. federal jurisdiction? If yes, attach a separate sheet with complete and accurate
explanation AND request all official disciplinary documents including initial complaint, stipulations, orders,
agreements or reprimands be sent directly to the Department. NO YES
7) Have you ever been admonished, reprimanded, censured and/or disciplined in any way by any professional or
medical society or association or committee thereof, 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 allegations
currently pending.) Disclose any stipulation to informal disposition in response to this question. If yes, attach a
separate sheet with complete and accurate explanation AND request all official disciplinary documents including
initial complaint, stipulations, orders, agreements or reprimands be sent directly to the Department. NO YES
8) Do you have any disease or condition that interferes with 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, that presently
interferes with your ability to practice your profession? If yes,attach a detailed statement, including an explanation
whether or not you are currently under treatment. NO YES
Under penalties of perjury, I declare that I have examined this Form and all supporting documents and/or
information submitted by me in connection therewith, and to the best of my knowledge, they are true,
correct, and complete.
Signature: ___________________________________________________ Date: ___________________________
FOR EXPEDITED REVIEW AND SERVICE, EMAIL COMPLETED FORM TO: email@example.com.
You will receive a Temporary Practice Permit via email.
All approved Temporary Practice Permits will have an expiration date of May 31, 2022 or until the
expiration of the Gubernatorial COVID-19 Disaster Proclamation and a $0 fee.
STATE OF ILLINOIS
DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION
DIVISION OF PROFESSIONAL REGULATION
In Re: Health Care Temporary Permit Application of ________________________________________________ (Applicant)
AFFIDAVIT OF _____________________________
I, ________________________________________ (Affiant), being duly sworn upon oath, depose and make this
Affidavit on my personal knowledge, and if sworn as a witness in this matter I would competently testify to the
1. I am a _____________________________________________________________________(position title)
working for ___________________________________________________________________(hospital or medical facility)
in __________________________________ (city), Illinois. I have held this role for ___________________(amount of time).
2. Part of my employment duties include reviewing applications for employment and/or credentialing at
3. I reviewed the application for employment of __________________________________________________(Applicant).
4. I reviewed a report from the National Practitioner Databank dated ____________________ , for
5. _________________________________________(Applicant) holds a ____________________________(license type)
in _________________________________(State of licensure).
6. Based upon my review of the application for employment and report from the National Practitioner Databank for
has a license in good standing in ______________________________(State of Original Licensure), has no prior disciplinary
actions against any license, and has no medical malpractice claims.
Under penalties as provide by law pursuant to Section 1-109 of the Illinois Civil Code of Procedure, I hereby affirm and
certify that the statements set forth in this Affidavit are true and correct.
FURTHER AFFIANT SAYETH NOT.
Date Name of Affiant
Subscribed and sworn to before me
this _______ day of ___________.
This form to be completed ONLY by an authorized representative of the hospital or medical facility located in
Illinois. Completed affidavit must be submitted to IDFPR with a Health Care Temporary Practice Application within
30 days of execution of the affidavit.
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