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 Ann & Robert H. Lurie Children's Hospital of Chicago or will be applying for staff membership (note: physicians practicing in the state of Indiana are not required to maintain staff privileges at Lurie Children's, 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. 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 Lurie Children's Medical and Dental Staff (or maintain staff membership at an approved Indiana hospital). This is a requirement for CCPA membership. For Lurie Children's staff membership, you will be charged a one-time credentialing fee of $250. Annual dues for active and associate staff members are $150. Please call the Lurie Children's Medical Staff Office at 312.227.4250 for someone who can assist you with this process, or download the Request for Application and Intended Practice Questionnaire and return it to the Medical Staff Office.
• An initial capital contribution to CCPA of $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 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 find the terms and conditions in the above documents agreeable, please use this Application Checklist to complete the CCPA Membership Application.  Please ensure that you complete ALL of the documents below: 
   • CCPA Attestation and Consent For Release of Information
   • Acknowledgement of Confidentiality
   • Illinois Credentialing and Data Gathering Form
   • CCPA Supplemental Questions Form
   • CCPA Special Interest and Media Survey
   • CCPA Managed Care Participation Form 
   • CCPA Managed Care Response Form
   • CCPA Find A Doctor Form
   • KIDS DOC Physician Referral Form
   • Physician Master Agreement Execution Page
   • Product Description Execution Page
3. If your practice is new to CCPA, please also complete the following documents:
   • W-9 Form
   • Practice Billing Information
   • Business Associate Agreement (please sign)
4. Submit your completed application materials to LaVonna Swilley

• Phone: 312.227.7425
• Fax: 312.227.9526
• Email: lswilley@luriechildrens.org
• Mailing address: 225 E. Chicago Avenue, Box 113, Chicago, IL 60611
• If you prefer to have these documents submitted in person, please contact your Physician Liaison to schedule a time when they may come to your office to pick them up.

Questions about the CCPA membership application?

Please contact LaVonna Swilley at 312.227.7425 or your dedicated Physician Liaison.