Joining CCPA

Eligiblity

Before you complete the necessary application and paperwork to join CCPA, please ensure that you are eligible to become a member of our group by answering yes to the following questions:

1. I am a board certified or board eligible pediatriciain or pediatric specialist.
2. I practice in the State of Illinois or Indiana.
3. I am currently on staff at Children’s Memorial Hospital or will be applying for staff membership (note: physicians practicing in the state of Indiana are not required to maintain staff privileges at Children’s Memorial Hospital, however, CCPA will verify Indiana hospital membership of these prospective members).

Becoming a member of this outstanding organization is a matter of a few simple and highly organized steps:

• We ask all interested physicians to complete an application for membership. For primary care pediatric practices, all CCPA-eligible physicians in the practice must join CCPA for the purposes of call coverage and quality management. See below for detailed membership application instructions.
• You must be a fully credentialed member of Children's Memorial's Medical and Dental Staff. This is a requirement for CCPA membership. You will be charged a one-time credentialing fee of $250. Annual dues for active and associate staff members are $150. Please contact your account executive to assist you with this process.
• An initial capital contribution to CCPA for $400 per pediatrician and $900 per pediatric specialist plus a $100 non-refundable credentialing fee is required when you submit your application. An annual payment of $150 per physician is also collected.

Instructions for membership application

To begin the application process to join CCPA, please follow these five steps:

1. Thoroughly review the CCPA Bylaws, CCPA Physician Master Agreement and the CCPA Product Description document. These documents outline the terms and conditions between CCPA and the physician, as well as for participation in CCPA's fee-for-service agreements.
2. If you are agreeable to the terms and conditions in the above documents, complete, in its entirety, the State of Illinois Health Care Professional Credentialing and Business Data Gathering Form. Please follow instructions outlined within the form. Here's a "tip" sheet to assist you in completing the form
3. In addition to the State of Illinois Credentialing application, please print and complete the following CCPA application forms:
   • CCPA Consent For Release of Information/Release from Liability
   • Supplemental Questions to State-Mandated Forms
   • CCPA Special Interest Survey
   • CCPA Billing Information Form
   • CCPA Managed Care Participation Form (Complete this form in order to receive e-mail notification of your effective dates with the plans you opt in to through CCPA.)
   • CCPA Managed Care Response Form (Complete this form in order to advise us of the plans you wish to opt in to through CCPA.)
   • CCPA Health Plans Participation Form for Find A Doctor (Complete this form in order to advise us of all of your managed care plans. We will use this information on your Find A Doctor profile on our Web site.)
   • KIDS DOC Practice Update Form
   • Request for Taxpayer Identification Number and Certification (W-9 Form)
   • Physician Master Agreement Execution Page
4. Review the CCPA Application Instructions to ensure you have read, completed, and are ready to submit all required items.
5. Submit your complete application materials:
   • You may mail your documents to:

   Priya Malviya
   Children's Community Physicians Association
   2300 Children's Plaza, #113
   Chicago, IL 60614-3363

   • If you prefer to have these documents submitted in person, please contact your account executive to schedule a time when they may come to your office to pick them up.

Questions about membership application?

Please contact Priya Malviya at 773.975.8747 or your dedicated account executive.