Louisiana Credentialing Application – Fill Out and Use This PDF

The Louisiana Credentialing Application form is designed for healthcare professionals to provide comprehensive information about their practice locations, qualifications, and services offered. This standardized form requires practitioners to detail their general information, practice locations, types of services available, accessibility features, and certifications in a structured format. If you are a healthcare provider looking to credential with various institutions or networks in Louisiana, ensure every section of this form is filled out completely and accurately. Click the button below to start filling out your form.

Get Form Now Download PDF

Louisiana Credentialing Application PDF Details

The Louisiana Standardized Credentialing Application serves as a comprehensive tool for healthcare professionals seeking credentialing in the state of Louisiana. It requires applicants to provide detailed personal and professional information to ensure a thorough evaluation of their qualifications. From basic personal data, such as name, contact information, gender, and educational background, to more intricate details regarding primary and additional practice locations, this form delves into every aspect necessary for credentialing. It encompasses sections on provider specialty and certification, clearly outlining the need for current certifications to be attached. Also, it extends into practice accessibility, with specific questions about compliance with the Americans with Disabilities Act (ADA), addressing the facility's physical accessibility and the availability of services for individuals with disabilities. Furthermore, the form inquires about practice availability, language services offered, and the age groups served, ensuring patients receive care tailored to diverse needs. It also seeks information on emergency after-hours coverage, indicating the importance of continuous patient care. With prompts for detailed responses and the directive to attach additional documentation as needed, the application underscores the rigorous standards set forth for healthcare providers in Louisiana, emphasizing the significance of transparency, due diligence, and the commitment to patient care accessibility and quality.

Question	Answer
Form Name	Louisiana Credentialing Application
Form Length	10 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 30 sec
Other names	Business ..., Hospital Services Corporation - 2121 Osuna Rd NE

Form Preview Example

LOUISIANA STANDARDIZED CREDENTIALING APPLICATION

DIRECTIONS

Please type or print in black ink when completing this form. If you need more space or have more than four locations, attach additional sheets and reference the question being answered. Please see page 10 for a list of required documents.

** All sections must be completed in their entirety. “See C.V.”, not acceptable**

GENERAL INFORMATION

Last Name

Suffix

First

Middle

Gender

 Male  Female

Degree:

 MD

 DO

 DPM

 DC

 DDS

 DMD

 Other________________

Any other name under which you have been known? (AKA) List

ECFMG Number

UPIN Number

Home Street Address

City

State

Zip Code

Home Phone Number

Pager Number/Answering Service

Home Email Address (optional)

Social Security Number

Date of Birth

Birth Place (City, State)

Race/Ethnicity (voluntary)

NPI - Individual

Medicaid Provider

Number

Medicare

Provider Number

PRIMARY PRACTICE LOCATION

Institution/Group/Clinic Name (If Applicable)		Office Manager

Tax Identification Number	Effective Date of Provider at this Practice Location	NPI – Group

Name to which Employer Identification Number (EIN) is registered with the IRS (IMPORTANT: must match IRS information exactly)

Physical Address

City

State

Zip Code

Office Email

Office Website

Main Phone Number

Appointment Phone

Number

Fax Number

Billing Address (Where you want payments sent)

Contact Person

Phone Number

City

State

Zip Code

Billing Email

Fax Number

Correspondence Address

(Where you want communications sent)

Contact Person

Phone Number

City

State

Zip Code

Correspondence Email

Fax Number

Medical Records Address

(Where you want medical record requests sent)

Contact Person

Phone Number

City

State

Zip Code

Medical Records Email

Fax Number

Type of Practice:

 Solo

 Multi-specialty Group

 Single Specialty Group

 Hospital-based

Hospital-employed  Healthplan/Payor-owned

If Hospital-employed or Healthplan/Payor-owned, please indicate owner name:__________________________________________

Office Hours	Mon.		Tues.		Wed.	Thur.	Fri.	Sat.	Sun.
Office Hours	_____-_____		_____-_____	_____-_____		_____-_____	_____-_____	_____-_____	_____-_____
	_____-_____		_____-_____	_____-_____		_____-_____	_____-_____	_____-_____	_____-_____
Do you practice at this location:		 Full-time		 Part-time		 Other (Specify) _______________________________

Languages spoken at this location (other than English):					____________________		____________________		Provider
Languages spoken at this location (other than English):					____________________		____________________		Other
									Other

Last Revised 01/2012	Page 1 of 10

PRIMARY PRACTICE LOCATION CONTINUED

Accepting Patients?

 New

 Only family members of existing patients

 Existing Only

 Other (Specify) _________________________________________________

Age group(s) treated:

 0-6 years

 7-11 years

 12-18 years

 19-65 years

 Over 65

 All Ages

 Other (Specify): ______________________________

Are PAs and/or nurse/paraprofessional

Yes No

Is this facility wheelchair/ handicapped

Yes No

practitioners used?

accessible?

Does the office offer handicapped access for:

Building: Yes No

Parking: Yes No

Restroom: Yes No

Other:

Accessible by public transportation: Bus: Yes No Courier Service: Yes No

Other:

Offers services for the disabled: Text Telephony (TTY): Yes No

American Sign Language: Yes No

Mental/Physical Impairment Services: Yes No

Other:

Does the office meet the Americans with Disabilities Act (ADA) accessibility requirements? Yes No

Emergency After Hours Number

Arrangements for 24 hour / 7 day a week coverage (Specify)

Group, Covering or

Collaborating Physician(s):

Contact Name:

Contact Phone Number:

SECOND PRACTICE LOCATION

Institution/Group/Clinic Name (If Applicable)

Office Manager

Tax Identification Number

Effective Date of Provider at this Practice Location

NPI – Group

Name to which Employer Identification Number (EIN) is registered with the IRS (IMPORTANT: must match IRS information exactly)

Physical Address

City

State

Zip Code

Office Email

Office Website

Main Phone Number

Appointment Phone

Number

Fax Number

Billing Address (Where you want payments sent)

Contact Person

Phone Number

City

State

Zip Code

Billing Email

Fax Number

Correspondence Address

(Where you want communications sent)

Contact Person

Phone Number

City

State

Zip Code

Correspondence Email

Fax Number

Medical Records Address

(Where you want medical record requests sent)

Contact Person

Phone Number

City

State

Zip Code

Medical Records Email

Fax Number

Type of Practice:

 Solo

 Multi-specialty Group

 Single Specialty Group

 Hospital-based

Hospital-employed  Healthplan/Payor-owned

If Hospital-employed or Healthplan/Payor-owned, please indicate owner name:__________________________________________

Office Hours	Mon.		Tues.		Wed.	Thur.	Fri.	Sat.	Sun.
Office Hours	_____-_____		_____-_____	_____-_____		_____-_____	_____-_____	_____-_____	_____-_____
	_____-_____		_____-_____	_____-_____		_____-_____	_____-_____	_____-_____	_____-_____
Do you practice at this location:		 Full-time		 Part-time		 Other (Specify) _______________________________

Languages spoken at this location (other than English):					____________________		____________________		Provider
Languages spoken at this location (other than English):					____________________		____________________		Other
									Other

Page 2 of 10

SECOND PRACTICE LOCATION CONTINUED

Accepting Patients?	 New	 Only family members of existing patients
	 Existing Only	 Other (Specify) _________________________________________________
Age group(s) treated:	 0-6 years	 7-11 years	 12-18 years	 19-65 years
Age group(s) treated:	 Over 65	 All Ages	 Other (Specify): ______________________________

Are PAs and/or nurse/paraprofessional	Yes No		Is this facility wheelchair/ handicapped				Yes No
practitioners used?	Yes No		accessible?				Yes No
practitioners used?			accessible?
Does the office offer handicapped access for: Building: Yes No				Parking: Yes No		Restroom: Yes No
		Other:

Accessible by public transportation:	Bus: Yes No Courier Service: Yes No				Other:

Offers services for the disabled: Text Telephony (TTY): Yes No				American Sign Language: Yes No
Mental/Physical Impairment Services: Yes No					Other:

Does the office meet the Americans with Disabilities Act (ADA) accessibility requirements? Yes No

Emergency After Hours Number		Arrangements for 24 hour / 7 day a week coverage (Specify)

Group, Covering or
Collaborating Physician(s):
Contact Name:				Contact Phone Number:

THIRD PRACTICE LOCATION

Institution/Group/Clinic Name (If Applicable)

Office Manager

Tax Identification Number

Effective Date of Provider at this Practice Location

NPI – Group

Name to which Employer Identification Number (EIN) is registered with the IRS (IMPORTANT: must match IRS information exactly)

Physical Address

City

State

Zip Code

Office Email

Office Website

Main Phone Number

Appointment Phone

Number

Fax Number

Billing Address (Where you want payments sent)

Contact Person

Phone Number

City

State

Zip Code

Billing Email

Fax Number

Correspondence Address

(Where you want communications sent)

Contact Person

Phone Number

City

State

Zip Code

Correspondence Email

Fax Number

Medical Records Address

(Where you want medical record requests sent)

Contact Person

Phone Number

City

State

Zip Code

Medical Records Email

Fax Number

Type of Practice:

 Solo

 Multi-specialty Group

 Single Specialty Group

 Hospital-based

 Hospital-employed

 Healthplan/Payor-owned

If Hospital-employed or Healthplan/Payor-owned, please indicate owner name:__________________________________________

Office Hours

Mon.

Tues.

Wed.

Thur.

Fri.

Sat.

Sun.

_____-_____

Do you practice at this location:

 Full-time

 Part-time

 Other (Specify) _______________________________

Languages spoken at this location (other than English):

____________________

Provider

Other

Accepting Patients?

 New

 Only family members of existing patients

 Existing Only

 Other (Specify) _________________________________________________

Page 3 of 10

How to Edit Louisiana Credentialing Application Online for Free

Having the goal of making it as simple to operate as it can be, we generated this PDF editor. The whole process of preparing the Business ... will be hassle-free in case you use the next actions.

Step 1: On the page, press the orange "Get form now" button.

Step 2: So, you can modify your Business .... The multifunctional toolbar helps you include, get rid of, alter, highlight, as well as undertake similar commands to the content and fields inside the file.

Enter the content demanded by the program to fill out the file.

part 1 to filling out Louisiana Credentialing Application

You need to provide the information within the box Billing Address Where you want, Contact Person, Phone Number, City, State, Zip Code, Billing Email, Fax Number, Correspondence Address Where you, Contact Person, Phone Number, City, State, Zip Code, and Correspondence Email.

part 2 to finishing Louisiana Credentialing Application

In the PRIMARY PRACTICE LOCATION CONTINUED, Accepting Patients, New Existing Only, Only family members of existing, Age groups treated, years Over, years All Ages, years Other Specify, years, Are PAs andor, Yes No, Is this facility wheelchair, Yes No, Does the office offer handicapped, and Building Yes No Other area, describe the important details.

Louisiana Credentialing Application PRIMARY PRACTICE LOCATION CONTINUED, Accepting Patients, New Existing Only, Only family members of existing, Age groups treated, years Over, years All Ages, years Other Specify, years, Are PAs andor, Yes No, Is this facility wheelchair, Yes No, Does the office offer handicapped, and Building Yes No Other blanks to fill

Spell out the rights and obligations of the parties in the section Name to which Employer, Physical Address, Office Email, City, Office Website, State, Zip Code, Main Phone Number, Appointment Phone Number, Fax Number, Billing Address Where you want, Contact Person, Phone Number, City, and State.

Entering details in Louisiana Credentialing Application stage 4

Check the sections Type of Practice, Solo Multispecialty Group, Single Specialty Group, Hospitalbased, HealthplanPayorowned If, Hospitalemployed, Office Hours, Mon, Tues, Wed, Thur, Fri, Sat, Sun, and Do you practice at this location and next complete them.

Type of Practice, Solo Multispecialty Group, Single Specialty Group, Hospitalbased, HealthplanPayorowned If, Hospitalemployed, Office Hours, Mon, Tues, Wed, Thur, Fri, Sat, Sun, and Do you practice at this location in Louisiana Credentialing Application

Step 3: Select the "Done" button. Now you may export the PDF document to your gadget. As well as that, you can deliver it through electronic mail.

Step 4: In order to prevent different risks down the road, you should generate as a minimum two or three duplicates of the file.

Louisiana Credentialing Application – Fill Out and Use This PDF

Louisiana Credentialing Application PDF Details

Form Preview Example

How to Edit Louisiana Credentialing Application Online for Free

Watch Louisiana Credentialing Application Video Instruction

Louisiana Credentialing Application isn’t the one you’re looking for?

Please rate Louisiana Credentialing Application

Louisiana Credentialing Application – Fill Out and Use This PDF

Louisiana Credentialing Application PDF Details

Form Preview Example

How to Edit Louisiana Credentialing Application Online for Free

Watch Louisiana Credentialing Application Video Instruction

Louisiana Credentialing Application isn’t the one you’re looking for?

Related Documents

Please rate Louisiana Credentialing Application

Related Resources