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Provider Sign Up

Complete this application to be listed in the Illinois Provider Directory. Step 1 asks for provider information. Step 2 asks for practice information. Step 3 asks you to verify your submission. An email will be sent to confirm your submission. Your listing will appear in the directory within 48 hours.

Step:

Your Information

* First Name:

* Last Name:

Please list your degrees and/or certifications.

Credentials:

* Ages Served:

Pediatric (children, age 0-21)
Adult (age 18 and older)

Gender:

This email address is only for ICAAP use and will not be displayed to the public.

* Your Email:

* Username:

* Password:

* Verify Password:

* Specialty Area:

Select the specialty areas from the list below that define your area of expertise and/or training.

Primary Care

	Family Medicine
	Internal Medicine

	Med-Peds
	Pediatrics

Specialty Care

	Allergy/Immunology
	Audiology
	Cardiac/Thoracic
	Dermatology
	Developmental Behavioral Pediatrics
	Endocrinology
	Gastroenterology
	Hematology/Oncology

	Infectious Disease
	Medical Genetics
	Neonatology
	Nephrology
	Neurology
	Obstetrics/Gynecology
	Orthopedics
	Otorhinolaryngology (Ear, Nose & Throat)

	Physical Medicine/Rehabilitation
	Podiatrist
	Pulmonology
	Reconstructive Surgery
	Rheumatology
	Surgery
	Urology
	Vision

Therapy Services

	Developmental Therapy
	Occupational Therapy

	Other Therapy
	Physical Therapy

Speech Therapy

Mental Health Services

	Counseling
	Psychiatry

	Psychology
	Social Work

Nutritional Services

Nutritionist/Dietitian

Dental Services

	Dentist
	Oral Surgeon

	Orthodontist
	Prosthodontist

Other

Area of Focus and
Special Services:

Types of Special Health
Care Needs Served:

Autism
Behavioral / Emotional
Complex Medical Conditions
Developmental
Learning
Physical
Sensory

Education/Training:

Terms and Conditions:

I acknowledge that this service is not a referral service and makes no endorsements as to the professional qualifications, licensing, or accuracy of any information provided. The site sponsors assume no responsibility for any services offered by the providers listed on this site.

I further acknowledge and agree that I am a currently licensed health care provider in good standing and am accessing this site to either add or edit my free listing in the database.

I also understand and agree that if I attempt to add or alter this database for any illicit or improper reason, it is possible that I may be acting in violation of one or more state and/or federal laws, and if such improper action is so discovered, the web site sponsors shall be expected to turn over any and all evidence of such potentially illicit or improper acts to the proper state or federal authorities.

I agree to the above terms and conditions

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