Louisiana Standardized Credentialing Application

Louisiana Standardized Credentialing Application PDF Details

If you need more space or have more than four locations, attach additional sheets and reference the question being answered.

Required documents: please see page 10 for a list of required documents.

References: three or more peers (Physicians of the same or similar specialty) who are familiar with your work effort and skills during the past two years.

Month and year: use the MONTH and YEAR for each entity listed; failure to provide this information may delay your credentialing.

Licenses in other states: please attach a copy of all licenses listed above and additional ones in other states not listed.