Louisiana Credentialing Application PDF Details

The Louisiana Credentialing Application Form is a document that needs to be completed by all healthcare professionals who wish to work in the state of Louisiana. The form is extensive, and requires detailed information about your qualifications, education, work history, and more. In order to make the process easier for you, we have put together a guide that will walk you through each section of the application form.

These are some facts you may want to check before starting working with the louisiana credentialing application.

QuestionAnswer
Form NameLouisiana Credentialing Application
Form Length10 pages
Fillable?Yes
Fillable fields713
Avg. time to fill out36 min 17 sec
Other namesBusiness ..., 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.

_____-_____

_____-_____

_____-_____

_____-_____

 

_____-_____

_____-_____

_____-_____

 

 

Do you practice at this location:

Full-time

Part-time

Other (Specify) _______________________________

 

 

 

 

 

 

 

 

 

 

 

Languages spoken at this location (other than English):

____________________

____________________

Provider

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.

_____-_____

_____-_____

_____-_____

_____-_____

 

_____-_____

_____-_____

_____-_____

 

 

Do you practice at this location:

Full-time

Part-time

Other (Specify) _______________________________

 

 

 

 

 

 

 

 

 

 

 

Languages spoken at this location (other than English):

____________________

____________________

Provider

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):

 

 

Yes No

 

 

From: _______ to _______

 

 

 

 

 

 

Residency: Institution Name

 

Type of Residency

 

Clinical

 

 

 

Research

 

 

 

 

 

City

 

State

 

 

Dates Attended (MO/YR):

 

 

 

 

 

From: _______ to _______

 

 

 

 

 

 

 

University Affiliation

 

Completed:

Yes

No

 

 

 

 

 

 

 

 

 

 

Residency: Institution Name

 

Type of Residency

 

Clinical

 

 

 

Research

 

 

 

 

 

City

 

State

 

 

Dates Attended (MO/YR):

 

 

 

 

 

From: _______ to _______

 

 

 

 

 

 

 

University Affiliation

 

Completed:

Yes

No

 

 

 

 

 

 

 

 

 

 

Fellowship: Institution Name

 

Specialty Field

 

 

Dates Attended (MO/YR):

 

 

 

 

 

From: _______ to _______

 

 

 

 

 

 

City

 

State

 

 

Completed

 

 

 

 

 

Yes

No

 

 

Type of Fellowship

 

Clinical

 

 

 

Research

 

 

 

 

 

 

 

 

 

 

Fellowship: Institution Name

 

Subspecialty Fields

 

Dates Attended (MO/YR):

 

 

 

 

 

From: _______ to _______

 

 

 

 

 

 

City

 

State

 

 

Completed

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

Type of Fellowship

 

Clinical

 

 

 

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

 

/

 

 

 

 

 

 

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:

Policy Number:

 

 

 

 

 

 

 

 

Address of Carrier:

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)

 

 

 

 

 

 

 

 

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

NO

N/A

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?

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?

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.

  

  

  

  

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.

X

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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