Ill. Admin. Code tit. 68 , 1130 app A - Notice of Order Requiring Chaperone

NOTICE OF ORDER REQUIRING CHAPERONE

The Illinois Department of Financial and Professional Regulation has ordered ***INSERT PRACTITIONER'S NAME*** to have a chaperone who is a licensed health care worker present during all patient encounters pending the outcome of criminal charges against him/her. In compliance with this Order, please sign below to acknowledge that you have received a copy of this notice.

The health care worker is presumed innocent until proven guilty of the charges.

Patient:

_____________________________________________________________

Print Name

___________________________________ ______________________

Signature Date

Chaperone:

_____________________________________________________________

Print Name

___________________________________ ______________________

Signature Date

Notes

Ill. Admin. Code tit. 68 , 1130 app A

Added at 37 Ill. Reg. 1192, effective February 1, 2013