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LHL234 | 01/07

Texas Standardized Credentialing Application

Pursuant to Texas Insurance Code § 1452.052, LHL234 Rev. 01/07 is promulgated by the Texas Department of Insurance. Please send this application to the carrier with whom you wish to become credentialed.

Section I-Individual Information

TYPE OF PROFESSIONAL

LAST NAME					FIRST			MIDDLE		(JR., SR., ETC.)

MAIDEN NAME					YEARS ASSOCIATED (YYYY-YYYY)		OTHER NAME			YEARS ASSOCIATED (YYYY-YYYY)

HOME MAILING ADDRESS

CITY						STATE/COUNTRY				POSTAL CODE

HOME PHONE NUMBER						SOCIAL SECURITY NUMBER
									Female	Male

CORRESPONDENCE ADDRESS

CITY						STATE/COUNTRY				POSTAL CODE

PHONE NUMBER				FAX NUMBER			E-MAIL

DATE OF BIRTH (MM/DD/YYYY)						PLACE OF BIRTH			CITIZENSHIP

IF NOT AMERICAN CITIZEN, VISA NUMBER & STATUS									ARE YOU ELIGIBLE TO WORK IN THE UNITED STATES?
									Yes No

U.S.MILITARY SERVICE/PUBLIC HEALTH						DATES OF SERVICE (MM/DD/YYYY) TO			LAST LOCATION
Yes	No					(MM/DD/YYYY)

BRANCH OF SERVICE						ARE YOU CURRENTLY ON ACTIVE OR RESERVE MILITARY DUTY?
						Yes No

Education

PROFESSIONAL DEGREE (MEDICAL, DENTAL, CHIROPRACTIC, ETC.)
Issuing Institution:

ADDRESS

CITY						STATE/COUNTRY				POSTAL CODE

DEGREE							ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

Please check this box and complete and submit Attachment A if you received other professional degrees.

POST-GRADUATE EDUCATION							SPECIALTY
Internship		Residency	Fellowship		Teaching Appointment

INSTITUTION

ADDRESS

CITY						STATE/COUNTRY				POSTAL CODE

							ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
Program successfully completed

PROGRAM DIRECTOR							CURRENT PROGRAM DIRECTOR (IF KNOWN)

POST-GRADUATE EDUCATION							SPECIALTY
Internship		Residency	Fellowship		Teaching Appointment

INSTITUTION

ADDRESS

CITY						STATE/COUNTRY				POSTAL CODE

										1 OF 20

Education - continued

POST-GRADUATE EDUCATION	ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
Program successfully completed

PROGRAM DIRECTOR	CURRENT PROGRAM DIRECTOR (IF KNOWN)

Please check this box and complete and submit Attachment B if you received additional postgraduate training.

OTHER GRADUATE-LEVEL EDUCATION

Issuing Institution:

ADDRESS

CITY	STATE/COUNTRY		POSTAL CODE

DEGREE		ATTENDANCE DATES (MM/YYYY TO MM/YYYY)

Licenses and Certificates - Please include all license(s) and certifications in all States where you are currently or have previously been licensed.

LICENSE TYPE					LICENSE NUMBER					STATE OF REGISTRATION

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)					EXPIRATION DATE (MM/DD/YYYY)					DO YOU CURRENTLY PRACTICE IN THIS STATE?
										Yes	No

LICENSE TYPE					LICENSE NUMBER					STATE OF REGISTRATION

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)					EXPIRATION DATE (MM/DD/YYYY)					DO YOU CURRENTLY PRACTICE IN THIS STATE?
										Yes	No

LICENSE TYPE					LICENSE NUMBER					STATE OF REGISTRATION

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)					EXPIRATION DATE (MM/DD/YYYY)					DO YOU CURRENTLY PRACTICE IN THIS STATE?
										Yes	No

					ORIGINAL DATE OF ISSUE (MM/DD/YYYY)					EXPIRATION DATE (MM/DD/YYYY)
DEA Number:

					ORIGINAL DATE OF ISSUE (MM/DD/YYYY)					EXPIRATION DATE (MM/DD/YYYY)
DPS Number:

OTHER CDS (PLEASE SPECIFY)					NUMBER					STATE OF REGISTRATION

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)					EXPIRATION DATE (MM/DD/YYYY)					DO YOU CURRENTLY PRACTICE IN THIS STATE?
										Yes	No

UPIN								NATIONAL PROVIDER IDENTIFIER (WHEN AVAILABLE)

ARE YOU A PARTICIPATING MEDICARE PROVIDER?								ARE YOU A PARTICIPATING MEDICAID PROVIDER?
Yes	No	Medicare Provider Number:						Yes No	Medicaid Provider Number:

EDUCATIONAL COUNCIL FOR FOREIGN MEDICAL GRADUATES (ECFMG)										ECFMG ISSUE DATE (MM/DD/YYYY)
N/A	Yes	No ECFMG Number:

Professional/Specialty Information

PRIMARY SPECIALTY					BOARD CERTIFIED?
					Yes	No	Name of Certifying Board:

INITIAL CERTIFICATION DATE (MM/YYYY)					RECERTIFICATION DATE(S), IF APPLICABLE (MM/YYYY)					EXPIRATION DATE, IF APPLICABLE (MM/YYYY)

IF NOT BOARD CERTIFIED, INDICATE ANY OF THE FOLLOWING THAT APPLY.
I have taken exam, results pending for			Board.
I have taken Part I and am eligible for Part II of the						Exam.
I am intending to sit for the Boards on			(date)
I am not planning to take Boards.
DO YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY?
HMO:	Yes	No PPO: Yes No	POS:	Yes No

SECONDARY SPECIALTY					BOARD CERTIFIED?
					Yes	No	Name of Certifying Board:

INITIAL CERTIFICATION DATE (MM/YYYY)					RECERTIFICATION DATE(S), IF APPLICABLE (MM/YYYY)					EXPIRATION DATE, IF APPLICABLE (MM/YYYY)

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Professional/Specialty Information -continued

IF NOT BOARD CERTIFIED, INDICATE ANY OF THE FOLLOWING THAT APPLY.

I have taken exam, results pending for	Board.
I have taken Part I and am eligible for Part II of the		Exam.
I am intending to sit for the Boards on	(date)

I am not planning to take Boards.

DO YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY?
HMO:	Yes	No PPO:	Yes	No	POS:	Yes	No

ADDITIONAL SPECIALTY							BOARD CERTIFIED?
							Yes No	Name of Certifying Board:

INITIAL CERTIFICATION DATE (MM/YYYY)							RECERTIFICATION DATE(S), IF APPLICABLE (MM/YYYY)		EXPIRATION DATE, IF APPLICABLE (MM/YYYY)

IF NOT BOARD CERTIFIED, INDICATE ANY OF THE FOLLOWING THAT APPLY.
I have taken exam, results pending for						Board.
I have taken Part I and am eligible for Part II of the							Exam.
I am intending to sit for the Boards on						(date)
I am not planning to take Boards.

DO YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY?
HMO:	Yes	No PPO:	Yes	No	POS:	Yes	No

PLEASE LIST OTHER AREAS OF PROFESSIONAL PRACTICE INTEREST OR FOCUS (HIV/AIDS, ETC.)

Work History - Please provide a chronological work history. You may submit a Curriculum Vitae as
a supplement. Please explain all gaps in employment that lasted more than six months.

CURRENT PRACTICE/EMPLOYER NAME									START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY								STATE/COUNTRY	POSTAL CODE

PREVIOUS PRACTICE/EMPLOYER NAME									START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY								STATE/COUNTRY	POSTAL CODE

REASON FOR DISCONTINUANCE

PREVIOUS PRACTICE/EMPLOYER NAME									START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY								STATE/COUNTRY	POSTAL CODE

REASON FOR DISCONTINUANCE

PREVIOUS PRACTICE/EMPLOYER NAME									START DATE/END DATE (MM/YYYY TO MM/YYYY)

ADDRESS

CITY								STATE/COUNTRY	POSTAL CODE

REASON FOR DISCONTINUANCE

PLEASE PROVIDE AN EXPLANATION FOR ANY GAPS GREATER THAN SIX MONTHS (MM/YYYY TO MM/YYYY) IN WORK HISTORY.
Gap Dates:			Explanation:
Gap Dates:			Explanation:

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Work History – continued

Gap Dates:		Explanation:

Gap Dates:		Explanation:

Please check this box and complete and submit Attachment C if you have additional work history

Hospital Affiliations-Please include all hospitals where you currently have or have previously had privileges.

DO YOU HAVE HOSPITAL PRIVILEGES?			IF YOU DO NOT HAVE ADMITTING PRIVILEGES, WHAT ADMITTING ARRANGEMENTS DO YOU HAVE?
Yes		No

PRIMARY HOSPITAL WHERE YOU HAVE ADMITTING PRIVILEGES						START DATE (MM/YYYY)

ADDRESS

CITY				STATE/COUNTRY			POSTAL CODE

PHONE NUMBER			FAX		E-MAIL

FULL UNRESTRICTED PRIVILEGES?			TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)			ARE PRIVILEGES TEMPORARY?
Yes		No				Yes	No

OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO PRIMARY HOSPITAL?

OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES						START DATE (MM/YYYY)

ADDRESS

CITY				STATE/COUNTRY			POSTAL CODE

PHONE NUMBER			FAX		E-MAIL

FULL UNRESTRICTED PRIVILEGES?			TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)			ARE PRIVILEGES TEMPORARY?
Yes		No				Yes	No

OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?

Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES						AFFILIATION DATES (MM/YYYY TO
						MM/YYYY)

ADDRESS

CITY				STATE/COUNTRY			POSTAL CODE

FULL UNRESTRICTED PRIVILEGES?			TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)			WERE PRIVILEGES TEMPORARY?
Yes	No					Yes	No

REASON FOR DISCONTINUANCE

Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.

References-Please provide three peer references from the same field and/or specialty who are not partners in your own group practice and are not relatives. All peer references should have firsthand knowledge of your abilities.

1 NAME/TITLE		PHONE NUMBER

ADDRESS

CITY	STATE/COUNTRY	POSTAL CODE

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References- continued

2NAME/TITLE

ADDRESS

PHONE NUMBER

CITY

STATE/COUNTRY

POSTAL CODE

3NAME/TITLE

PHONE NUMBER

ADDRESS

CITYSTATE/COUNTRYPOSTAL CODE

Professional Liability Insurance Coverage

SELF-INSURED?	NAME OF CURRENT MALPRACTICE INSURANCE CARRIER OR SELF-INSURED ENTITY
Yes No

ADDRESS

CITY		STATE/COUNTRY			POSTAL CODE

PHONE NUMBER		POLICY NUMBER	EFFECTIVE DATE (MM/DD/YYYY)		EXPIRATION DATE (MM/DD/YYYY)

AMOUNT OF COVERAGE PER		AMOUNT OF COVERAGE AGGREGATE	TYPE OF COVERAGE		LENGTH OF TIME WITH CARRIER
OCCURRENCE			Individual	Shared

NAME OF PREVIOUS MALPRACTICE INSURANCE CARRIER IF WITH CURRENT CARRIER LESS THAN 5 YEARS

ADDRESS

CITY		STATE/COUNTRY			POSTAL CODE

PHONE NUMBER		POLICY NUMBER	EFFECTIVE DATE (MM/DD/YYYY)		EXPIRATION DATE (MM/DD/YYYY)

AMOUNT OF COVERAGE PER		AMOUNT OF COVERAGE AGGREGATE	TYPE OF COVERAGE		LENGTH OF TIME WITH CARRIER
OCCURRENCE			Individual	Shared

Call Coverage

See attached list of hospital staff within my department I utilize for call coverage.

PLEASE LIST NAMES OF COLLEAGUE(S) PROVIDING REGULAR COVERAGE AND HIS OR HER SPECIALTIES.
Name:		Specialty:

Name:		Specialty:

Name:		Specialty:

Name:		Specialty:

Name:		Specialty:

PLEASE LIST FULL NAMES OF ALL PARTNERS IN YOUR PRACTICE. CHECK THIS BOX AND ATTACH LIST FOR LARGE GROUP.
Name:		Name:

Name:		Name:

Name:		Name:

Name:		Name:

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Question	Answer
Form Name	Texas Credentialing Application
Form Length	20 pages
Fillable?	Yes
Fillable fields	1097
Avg. time to fill out	37 min 24 sec
Other names	standardized texas form pdf, credentialing application texas, texas standardized credentialing application, texas standardized prior authorization form

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