Louisiana Credentialing Application ≡ Fill Out Printable PDF Forms Online

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	Hospital Services Corporation - 2121 Osuna Rd NE

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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

Office Email

City	State	Zip Code

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

 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:

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

THIRD PRACTICE LOCATION CONTINUED

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:

FOURTH PRACTICE LOCATION

(If you have more than four locations, attach additional sheets with the following information.)

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 4 of 10

FOURTH PRACTICE LOCATION CONTINUED

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:

SPECIALTY & CERTIFICATION

(as recognized by American Board of Medical Specialties or other national certification body)

Please attach a copy of current certification(s).

Type of Provider:  Primary Care Physician	 Physician Specialist		 Both	 Other Specialty:__________________

Primary Specialty:		Specialty Board Certified By:

Second Specialty:		Specialty Board Certified By:

Third Specialty:		Specialty Board Certified By:

DIRECTORY INFORMATION

Check whether the specialty and/or subspecialty(ies) listed above are practiced at each location. Indicate if each specialty is to be noted in the directory. Disclaimer: Use of information may vary by healthcare organization.

Primary Location	Second Location	Third Location	Fourth Location
 Specialty	 Specialty	 Specialty	 Specialty
 Directory	 Directory	 Directory	 Directory
 Sub-specialty	 Sub-specialty	 Sub-specialty	 Sub-specialty
 Directory	 Directory	 Directory	 Directory
 Sub-specialty	 Sub-specialty	 Sub-specialty	 Sub-specialty
 Directory	 Directory	 Directory	 Directory

PHO / IPA AFFILIATIONS*

List any other PHO’s, IPA’s, which you participate in and dates of participation:

*The intent of this section is to identify any contractual arrangements the physicians have that are in direct conflict with the Plan.

Page 5 of 10

CURRENT HOSPITAL AFFILIATION

List the hospital to which you primarily admit your patients:

List in chronological order from oldest to most current all hospitals at which you currently have privileges:

			Effective Date
Hospital	Location/Address	Type of Privileges	MO/YR

If you do not have admitting privileges, who admits for you and to what hospital? Please list provider's name, specialty and hospital.

EDUCATION

If additional training to what is requested below has been completed, please attach on a separate form.

Medical/Professional School:

City		State			Zip

Degree		Year of Graduation			Dates Attended (MO/YR):
					From: _______ to _______

Internship: Institution Name		Type of Training

City		State

University Affiliation		Completed			Dates Attended (MO/YR):
		Completed
		 Yes  No			From: _______ to _______

Residency: Institution Name		Type of Residency			 Clinical
		Type of Residency			 Research
					 Research

City		State			Dates Attended (MO/YR):
					From: _______ to _______

University Affiliation		Completed:	 Yes	 No
		Completed:	 Yes	 No

Residency: Institution Name		Type of Residency			 Clinical
		Type of Residency			 Research
					 Research

City		State			Dates Attended (MO/YR):
					From: _______ to _______

University Affiliation		Completed:	 Yes	 No
		Completed:	 Yes	 No

Fellowship: Institution Name		Specialty Field			Dates Attended (MO/YR):
					From: _______ to _______

City		State			Completed
					 Yes	 No
		Type of Fellowship			 Clinical
		Type of Fellowship			 Research
					 Research

Fellowship: Institution Name		Subspecialty Fields			Dates Attended (MO/YR):
					From: _______ to _______

City		State			Completed
					 Yes	 No

		Type of Fellowship			 Clinical
		Type of Fellowship			 Research
					 Research
	Page 6 of 10

WORK HISTORY

Using the following codes, please list in chronological order from oldest to most current your work history from the time you completed your medical training to the present. It is very important that you use the MONTH and YEAR for each entity listed.

Work history is critical. Failure to provide this information may delay your credentialing.

Code:
C = Clinic/Group		S = Solo Practice	A = Academic (Paid Teaching Appointments)
H = Civilian Hospital Medical Staff Appointment M = Military Service (Including Hospital Staff Appointments)						O = Other
	CODE	NAME AND ADDRESS OF ENTITY		DATE (From MO/YR to MO/YR)
				/	to		/
				/	to		/
				/	to		/
				/	to		/
				/	to		/
				/	to		/
				/	to		/
				/	to		/
				/	to		/
				/	to		/
				/	to		/
				/	to		/
				/	to		/
				/	to		/
				/	to		/

WORK HISTORY GAP

In the following section, please explain any gaps of two months or more in your education, post-graduate training or work history.

Failure to provide this information may delay your credentialing

Page 7 of 10

PROFESSIONAL LICENSES

Professional Licenses	License Number	Date Obtained	Expiration Date

State License

Federal DEA Reg Number

State CDS License Number

CLIA Certificate

Are laboratory testing procedures (as covered by the Clinical Improvement Act – CLIA) currently being performed at your office site where members are seen?

 Yes  No If yes, a current copy of your CLIA Registration must accompany this application.

For Dentists Only - Do you perform any procedures in the office setting utilizing conscious sedation or any anesthesia (other than oral analgesic?)

 Yes  No If yes, a copy of your Anesthesia Permit must accompany this application.

Have you been or are you currently licensed in any other state? If YES, please complete the following:

License Number	State	Date Obtained	Expiration Date

License Number	State	Date Obtained	Expiration Date

License Number	State	Date Obtained	Expiration Date

(Please attach a copy of all licenses listed above and additional ones in other states not listed.)

REFERENCES

List, as professional 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.

(References should not be relatives or current partners.)

Name	Specialty	Phone Number

Street Address	City	State	Zip

Name	Specialty	Phone Number

Street Address	City	State	Zip

Name	Specialty	Phone Number

Street Address	City	State	Zip

Name	Specialty	Phone Number

Street Address	City	State	Zip

Page 8 of 10

PROFESSIONAL LIABILITY INSURANCE COVERAGE

Name of Carrier:

Address of Carrier:

Policy Number:

Phone Number:

Amounts Per Occurrence/Aggregate:

Dates of Coverage:

Do you participate in the Louisiana Patients’ Compensation Fund?	 Yes	 No

Are you self-insured in accordance with the Louisiana Medical Malpractice Act?	 Yes	 No

Has current liability insurance carrier required exclusion of any procedures from insurance	 Yes	 No
coverage? (If yes, attach explanation)	 Yes	 No
coverage? (If yes, attach explanation)

Please attach a copy of the current Certificates of Insurance.

GENERAL QUESTIONS

Please check the appropriate response to the following questions:
If you answered YES to any of the questions below, please attach a full explanation on a separate page.		YES

1.	Has any disciplinary action ever been instituted against your license to practice in your profession in		
	any state or country, or is any such action currently pending against you?


2.	Has any disciplinary action ever been instituted against your DEA registration or CDS license, or		
	have you voluntarily surrendered or limited your registration, or is any such action pending?


3.	Have you ever been convicted of, or pleaded nolo contendere to, or are you currently under		
	investigation for federal or state felony or other criminal charge or have you ever served a prison

	sentence?

4.	Have you ever been suspended from the Medicare or Medicaid program, or has your participation		
	status ever been modified?
	status ever been modified?

5.	Have your clinical privileges at any hospital or healthcare institutions been voluntarily or involuntarily		
	revoked, not renewed, or subjected to probationary or other disciplinary conditions, or has any

	proceeding been instituted or recommended by a hospital administration, medical staff committee
	or governing board?

6.	Have you ever received a sanction from any regulatory agency (e.g., CLIA, OSHA, etc.)?		


7.	Have you engaged in the illegal use of drugs within the past two years? “Illegal use of drugs”		
	means the use of controlled substances obtained illegally, not obtained pursuant to a valid

	prescription or not taken in accordance with the direction of a licensed healthcare practitioner.

8.	Do you currently have any ongoing physical or mental impairment or condition which would make		
	you unable, with or without reasonable accommodation, to perform the essential functions of a

	practitioner in your area of practice, or unable to perform those essential functions without a direct
	threat to the health and safety of others?

9.	Do you, your business entity or any family member have an ownership greater than 5% in any		
	medical enterprise or business?
	medical enterprise or business?
	If YES, please enter the ownership percentage ____________ and attach a full explanation.

10.	Are you presently a named defendant in a pending professional liability lawsuit?		
	If YES, please enter the number of cases ____________ and attach a full explanation of each.


11.	During the past 5 years has any adverse medical review panel opinion been rendered, has any		
	settlement or judgment been made, or has any payment been made by you or on your behalf in a

	professional liability action or potential action?
	If YES, please enter the number of cases _____________ and attach a full explanation of each.



N/A



Page 9 of 10

REQUIRED ATTACHMENTS

State Licenses including current licenses held in other states, State CDS license and Federal DEA Registration

Curriculum Vitae

Certificate(s) of Professional Liability Insurance

History of Malpractice suits in past 5 years, regardless of whether judgments or settlements paid.

Explanation of any “Yes” Answer(s) from General Questions Section on page 9.

Current Employer Identification Number (EIN) and W-9 Form or Federal Tax Deposit Coupon

Education Certificate for Foreign Medical Graduates (ECFMG) (If applicable)

Health Plan Agreement (If applicable)

STATEMENT TO APPLICANTS

All providers applying for network participation have the right to review the credentialing application and supporting documents. Exceptions may vary as prohibited by law or health plan policy.

In the event that credentialing information obtained from other sources varies substantially from the information submitted on this application, you will be notified of the discrepancy either by telephone or in writing. You will have the opportunity to submit additional information to correct the discrepancy or provide clarification that might positively impact the credentialing decision.

According to La. R.S. 22:1009 (A) (8) an adverse medical review panel opinion is included in the type of information a health plan may require you to submit on a credentialing or re-credentialing application.

According to La. R.S. 22:1009, a health insurance issuer is required to complete the credentialing process within 90 days from the date of receipt of all information needed. The issuer is required to inform you within 30 days of receipt all defects and reasons known at the time in the event an application is deemed to be not correctly completed. The issuer is also required to inform you in the event that any needed verification or verification supporting statement has not been received from a third party within 60 days of the date of such a request.

PROVIDER STATEMENT TO RELEASE INFORMATION

All information and documentation submitted by me in this application is correct and complete to my best knowledge and belief.

I acknowledge that any material misstatements in or omissions from this application may constitute cause for denial of my application for network participation.

I consent to the release of all information that may be relevant to an evaluation of my credentials, including information about disciplinary actions or other confidential or privileged information, to Plan or its affiliates or successors. I understand and agree that this consent is irrevocable for any period during which I am Plan provider. I release Plan, its affiliates and successors and their representatives from any and all liability for their acts performed in good faith and without malice in obtaining information and evaluating my credentials. Plan is defined as the Health Plan that is requesting the credentialing information.

Name (Please Print)		Signature	Original Attestation Date

	Second Attestation Date		Third Attestation Date

Plan accreditation guidelines may require this application signature date to be

no more than 180 days old at the time of credentialing.

Page 10 of 10

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