Texas Credentialing Application PDF Details

Have you ever had to apply for a Texas credential? If you have, then you know that the application process can be time consuming and a bit overwhelming. Thankfully, there is now a new form that makes the application process much easier. The Texas Credentialing Application Form (TCAF) was released in early 2017 and has been helping applicants since then. Let's take a closer look at what TCAF is and how it can make your life easier. The Texas Credentialing Application Form (TCAF) is an online form that was released in early 2017. This form replaces the applications for both educator and administrator credentials in Texas, making the application process much easier for applicants.

You'll discover details about the type of form you intend to submit in the table. It will show you the length of time you will require to finish texas credentialing application, what fields you will have to fill in and a few additional specific details.

QuestionAnswer
Form NameTexas Credentialing Application
Form Length20 pages
Fillable?No
Fillable fields0
Avg. time to fill out5 min
Other namestexas standard credentialing application pdf, texas credentialing, texas standardized application for p, standardized texas form pdf

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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.

Texas Standardized Credentialing Application

 

(Pl e a s e t yp e o r p r i n t

 

 

 

 

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

CORRESPONDENCE ADDRESS

SOCIAL SECURITY NUMBER

Female Male

CITY

PHONE NUMBER

STATE/COUNTRY

POSTAL CODE

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 (MM/DD/YYYY)

LAST LOCATION

Yes

No

 

 

 

 

 

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 t his box and complete and submit At tachment A if you received other professional degrees.

POST-GRADUATE EDUCATIONSPECIALTY

Internship Residency Fellowship Teaching Appointment

INSTITUTION

ADDRESS

CITY

STATE/COUNTRY

POSTAL CODE

Program successfully completed

PROGRAM DIRECTOR

ATTENDANCE DATES (MM/YYYY TO MM/YYYY)

CURRENT PROGRAM DIRECTOR (IF KNOWN)

POST-GRADUATE EDUCATION

 

SPECIALTY

 

Internship

Residency

Fellowship

Teaching Appointment

 

 

 

 

 

 

INSTITUTION

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

CITY

 

 

STATE/COUNTRY

POSTAL CODE

 

 

 

 

 

LHL234 REV.01/07

1 OF 20

Education - continued

POST-GRADUATE EDUCATION Program successfully completed

PROGRAM DIRECTOR

ATTENDANCE DATES (MM/YYYY TO MM/YYYY)

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)

LICENSE TYPE

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

LICENSE TYPE

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

DEA Number:

DPS Number:

OTHER CDS (PLEASE SPECIFY)

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

LICENSE NUMBER

EXPIRATION DATE (MM/DD/YYYY)

LICENSE NUMBER

EXPIRATION DATE (MM/DD/YYYY)

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

NUMBER

EXPIRATION DATE (MM/DD/YYYY)

DO YOU CURRENTLY PRACTICE IN THIS STATE?

Yes No

STATE OF REGISTRATION

DO YOU CURRENTLY PRACTICE IN THIS STATE?

Yes No

STATE OF REGISTRATION

DO YOU CURRENTLY PRACTICE IN THIS STATE?

Yes No

EXPIRATION DATE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

STATE OF REGISTRATION

DO YOU CURRENTLY PRACTICE IN THIS STATE?

Yes No

UPIN

NATIONAL PROVIDER IDENTIFIER (WHEN AVAILABLE)

ARE YOU A PARTICIPATING MEDICARE PROVIDER?

Yes

No

Medicare Provider Number:

EDUCATIONAL COUNCIL FOR FOREIGN MEDICAL GRADUATES (ECFMG)

N/A Yes No ECFMG Number:

ARE YOU A PARTICIPATING MEDICAID PROVIDER?

Yes No

Medicare Provider Number:

 

 

 

 

 

ECFMG ISSUE DATE (MM/DD/YYYY)

 

 

 

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)

 

 

 

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

 

I have taken exam, results pending for

Board.

 

EXPIRATION DATE, IF APPLICABLE (MM/YYYY)

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)

LHL234 REV.01/07

2 OF 20

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)

 

 

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

I have taken exam, results pending for

Board.

EXPIRATION DATE, IF APPLICABLE (MM/YYYY)

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 - Pl ease provi de a chronol ogi cal work hi st ory. You may submi t a Curri cul um Vi t ae as a suppl ement . Pl ease expl ai n al l gaps i n empl oyment t hat l ast ed more t han si x mont hs.

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:

 

 

 

 

LHL234 REV.01/07

3 OF 20

Work History cont inued

Gap Dates:

Explanation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gap Dates:

Explanation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check t his box and complet e and submit At t achment C if you have addit ional work hist ory

 

 

 

 

 

 

 

 

 

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 t his box and complet e and submit At t achment D if you have addit ional current hospit al affiliat ions.

 

 

 

 

 

 

 

 

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 t his box and complet e and submit At t achment E if you have addit ional previous hospit al affiliat ions.

References-Please provide t hree peer references from t he same field and/ or specialt y who are not part ners in your own group pract ice and are not relat ives. All peer references should have first hand knowledge of your abilit ies.

1

NAME/TITLE

 

PHONE NUMBER

 

 

 

ADDRESS

 

 

 

 

 

 

CITY

 

STATE/COUNTRY

POSTAL CODE

 

 

 

 

LHL234 REV.01/07

4 OF 20

References- continued

2 NAME/TITLE

 

PHONE NUMBER

 

 

 

ADDRESS

 

 

 

 

 

CITY

STATE/COUNTRY

POSTAL CODE

 

 

 

3 NAME/TITLE

 

PHONE NUMBER

 

 

 

ADDRESS

 

 

 

 

 

CITY

STATE/COUNTRY

POSTAL 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 OCCURRENCE

AMOUNT OF COVERAGE AGGREGATE

 

TYPE OF COVERAGE

LENGTH OF TIME WITH CARRIER

 

 

 

 

 

 

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 OCCURRENCE

AMOUNT OF COVERAGE AGGREGATE

 

TYPE OF COVERAGE

LENGTH OF TIME WITH CARRIER

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

 

 

 

 

LHL234 REV.01/07

5 OF 20

Practice Location Information Please answer the following questions for each practice location. Use Attachment F or make

PRACTICE LOCATION

copies of pages 6-7 as necessary.

 

 

 

 

of

TYPE OF SERVICE PROVIDED

 

 

 

 

 

Solo Primary Care

Solo Specialty Care

Group Primary Care

Group Single Specialty

Group Multi-Specialty

 

 

 

 

 

 

GROUP NAME/PRACTICE NAME TO APPEAR IN THE DIRECTORY

 

GROUP/CORPORATE NAME AS IT APPEARS ON IRS W-9

 

 

 

 

 

 

PRACTICE LOCATION ADDRESS

 

 

 

 

 

Primary

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

STATE/COUNTRY

 

POSTAL CODE

 

 

 

 

 

 

 

PHONE NUMBER

FAX NUMBER

E-MAIL

BACK OFFICE PHONE NUMBER

GROUP NUMBER CORRESPONDING TO TAX ID NUMBER

ARE YOU CURRENTLY PRACTICING AT THIS LOCATION?

Yes No

OFFICE MANAGER OR STAFF CONTACT

 

 

 

 

 

 

 

 

 

 

SITE-SPECIFIC MEDICAID NUMBER

 

TAX ID NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

GROUP NAME CORRESPONDING TO TAX ID NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

IF NO, EXPECTED START DATE? (MM/DD/YYYY)

 

DO YOU WANT THIS LOCATION LISTED IN THE

 

 

 

 

 

 

DIRECTORY?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

PHONE NUMBER

 

 

FAX NUMBER

 

 

 

 

 

 

 

 

 

 

CREDENTIALING CONTACT

ADDRESS

CITY

STATE/COUNTRY

POSTAL CODE

PHONE NUMBER

FAX NUMBER

E-MAIL

BILLING COMPANYS NAME (IF APPLICABLE)

BILLING REPRESENTATIVE

ADDRESS

CITY

PHONE NUMBER

DEPARTMENT NAME IF HOSPITAL-BASED

 

STATE/COUNTRY

 

POSTAL CODE

 

 

 

 

 

FAX NUMBER

 

E-MAIL

 

 

 

 

 

 

 

CHECK PAYABLE TO

CAN YOU BILL ELECTRONICALLY?

 

 

 

Yes

No

 

 

 

 

 

HOURS PATIENTS ARE SEEN

 

 

 

Monday

No Office Hours

Morning:

Afternoon:

Evening:

Tuesday

No Office Hours

Morning:

Afternoon:

Evening:

Wednesday

No Office Hours

Morning:

Afternoon:

Evening:

Thursday

No Office Hours

Morning:

Afternoon:

Evening:

Friday

No Office Hours

Morning:

Afternoon:

Evening:

Saturday

No Office Hours

Morning:

Afternoon:

Evening:

Sunday

No Office Hours

Morning:

Afternoon:

Evening:

DOES THIS LOCATION PROVIDE 24 HOUR/7 DAY A WEEK PHONE COVERAGE?

 

 

 

Answering Service

Voice mail with instructions to call answering service

Voice mail with other instructions

None

 

 

 

 

 

 

THIS PRACTICE LOCATION ACCEPTS

 

 

 

 

 

all new patients

existing patients with change of payor

new patients with referral

new Medicare patients

new Medicaid patients

 

 

 

 

IF NEW PATIENT ACCEPTANCE VARIES BY HEALTH PLAN, PLEASE PROVIDE EXPLANATION.

 

 

 

 

 

 

 

 

 

 

PRACTICE LIMITATIONS

 

 

 

 

 

 

Male only

Female only

Age:

Other:

 

 

 

 

DO NURSE PRACTITIONERS, PHYSICIAN ASSISTANTS, MIDWIVES, SOCIAL WORKERS OR OTHER NON-PHYSICIAN PROVIDERS CARE FOR PATIENTS AT THIS PRACTICE LOCATION?

Yes No

If yes, provide the following information for each staff member:

 

 

 

 

 

 

 

 

 

NAME

 

 

PROFESSIONAL DESIGNATION

 

STATE & LICENSE NO.

 

 

 

 

 

 

NAME

 

 

PROFESSIONAL DESIGNATION

 

STATE & LICENSE NO.

 

 

 

 

 

 

 

LHL234 REV.01/07

6 OF 20

Practice Location Information - continued

NAME

 

 

 

 

PROFESSIONAL DESIGNATION

 

STATE & LICENSE NO.

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

PROFESSIONAL DESIGNATION

 

STATE & LICENSE NO.

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

PROFESSIONAL DESIGNATION

 

STATE & LICENSE NO.

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

PROFESSIONAL DESIGNATION

 

STATE & LICENSE NO.

 

 

 

 

NON-ENGLISH LANGUAGES SPOKEN BY HEALTH CARE PROVIDERS

 

 

NON-ENGLISH LANGUAGES SPOKEN BY OFFICE PERSONNEL

 

 

 

 

 

 

 

 

 

 

ARE INTERPRETERS AVAILABLE?

 

 

 

 

 

 

 

 

 

Yes

No If yes, please specify languages:

 

 

 

 

 

 

 

 

 

 

 

 

DOES THIS PRACTICE LOCATION MEET ADA ACCESSIBILITY STANDARDS?

 

 

WHICH OF THE FOLLOWING FACILITIES ARE HANDICAPPED ACCESSIBLE?

Yes

No

 

 

 

 

 

 

 

Building Parking Restroom

Other:

 

 

 

 

 

 

 

 

DOES THIS LOCATION HAVE OTHER SERVICES FOR THE DISABLED?

 

 

 

 

 

 

Text Telephony-TTY

American Sign Language-ASL

Mental/Physical Impairment Services

0ther:

 

 

 

 

 

 

 

 

 

 

IS THIS LOCATION ACCESSIBLE BY PUBLIC TRANSPORTATION?

 

 

 

 

 

 

 

Bus

Regional Train

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOES THIS LOCATION PROVIDE CHILDCARE SERVICES?

 

 

 

 

DOES THIS LOCATION QUALIFY AS A MINORITY BUSINESS ENTERPRISE?

Yes

No

 

 

 

 

 

 

 

Yes No

 

 

 

 

 

WHO AT THIS LOCATION HAVE THE FOLLOWING CURRENT CERTIFICATIONS? (PLEASE LIST ONLY THE APPLICANT'S CERTIFICATION EXPIRATION DATES.)

 

Basic Life Support

 

Staff

 

Provider Exp:

 

Advanced Life Support in OB

Staff

Provider Exp:

Advanced Trauma Life Support

Staff

 

Provider Exp:

 

Cardio-Pulmonary Resuscitation

Staff

Provider Exp:

Advanced Cardiac Life Support

Staff

 

Provider Exp:

 

Pediatric Advanced Life Support

Staff

Provider Exp:

Neonatal Advanced Life Support

Staff

 

Provider Exp:

 

Other (please specify)

Staff

Provider Exp:

 

 

 

 

 

 

DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE?

Yes

No

 

 

 

Laboratory Services; please list all Certificates of Participation

(CLIA, AAFP, COLA, CAP, MLE):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE?

Yes

X-ray; please list all certifications:

 

No

OTHER SERVICES

 

 

 

Radiology Services

EKG

Care of Minor Lacerations

Pulmonary Function Tests

Allergy Injections

Allergy Skin Tests

Routine Office Gynecology

Drawing Blood

Age Appropriate Immunizations

Flexible Sigmoidoscopy

Tympanometry/Audiometry Tests

Asthma Treatments

Osteopathic Manipulations

IV Hydration /Treatments

Cardiac Stress Tests

Physical Therapies

Other:

 

 

 

 

 

 

 

PLEASE LIST ANY ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)

 

IS ANESTHESIA ADMINISTERED AT THIS PRACTICE LOCATION?

WHO ADMINISTERS IT?

 

Yes

No Please specify the classes or categories:

 

 

 

 

 

Please check this box and complete and submit Attachment F if you have other practice locations.

 

 

 

 

 

LHL234 REV.01/07

7 OF 20

Section II-Disclosure Questions - Please provide an explanation for any question answered yes-except 16-on page 10.

Licensure

1Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, or have you ever been subject to a consent order, probation or any conditions or limitations by any state licensing board?

Yes No

2 Have you ever received a reprimand or been fined by any state licensing board?

Yes No

Hospital Privileges and Other Affiliations

3Have your clinical privileges or Medical Staff membership at any hospital or healthcare institution ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical records when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board?

Yes No

4 Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?

Yes No

5Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)?

Yes No

Education, Training and Board Certification

6Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign?

Yes No

7Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?

Yes No

8 Have any of your board certifications or eligibility ever been revoked?

Yes No

9 Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?

Yes No

DEA or DPS

10Have your Federal DEA and/ or DPS Controlled Substances Certificate(s) or authorization(s) ever been denied, suspended, revoked, restricted, denied renewal, or voluntarily relinquished?

Yes No

Medicare, Medicaid or other Governmental Program Participation

11Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, dis- qualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs?

Yes No

Other Sanctions or Investigations

12Are you currently or have you ever been the subject of an investigation by any hospital, licensing authority, DEA or DPS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program?

Yes No

LHL234 REV.01/07

8 OF 20

Section II - Disclosure Questions - continued

Other Sanctions or Investigations

13To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?

Yes No

14Have you ever received sanctions from or been the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)?

Yes No

15Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation by a hospital or healthcare facility of any military agency?

Yes No

Malpractice Claims History

16 Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?

Yes No

If yes, please check this box and complete and submit Attachment G.

Criminal

17Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony that is reasonably related to your qualifications, competence, functions, or duties as a medical professional

Yes No

18Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony including an act of violence, child abuse or a sexual offense?

Yes No

19 Have you been court-martialed for actions related to your duties as a medical professional?

Yes No

Ability to Perform Job

20Are you currently engaged in the illegal use of drugs? ("Currently" means sufficiently recent to justify a reasonable belief that the use of drug may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22. It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription controlled substances.)

Yes No

21Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety?

Yes No

Ability to Perform Job

22 Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients?

Yes No

23Are you unable to perform the essential functions of a practitioner in your area of practice, with or without rea- sonable accommodation?

Yes No

Please use the space on page 10 to explain yes answers to any question except #16.

LHL234 REV.01/07

9 OF 20

Section II - Disclosure Questions- continued

Please use the space below to explain yes answers to any question except 16.

QUESTION NUMBER

PLEASE EXPLAIN

LHL234 REV.01/07

10 OF 20

Section III Standard Authorization, Attestation and Release (Not for Use for Employment Purposes)

I understand and agree that, as part of the credentialing application process for participation andor clinical privileges (hereinafter, referred to as Participation) at or with

(PLEASE INDICATE MANAGED CARE COMPANY(S) OR HOSPITAL(S) TO WHICH YOU ARE APPLYING) (HEREINAFTER, INDIVIDUALLY REFERRED TO AS THE ENTITY)

and any of the Entity s affiliated entities, I am required to provide sufficient and accurate information for a proper evaluation of my current licensure, relevant training and or experience, clinical competence, health status, character, ethics, and any other criteria used by the Entity for determining initial and ongoing eligibility for Participation. Each Entity and its representatives, employees, and agent(s) acknowledge that the information obtained relating to the application process will be held confidential to the extent permitted by law.

I acknowledge that each Entity has its own criteria for acceptance, and I may be accepted or rejected by each independently. I further acknowledge and understand that my cooperation in obtaining information and my consent to the release of information do not guarantee that any Entity will grant me clinical privileges or contract with me as a provider of services. I understand that my application for Participation with the Entity is not an application for employment with the Entity and that acceptance of my application by the Entity will not result in my employment by the Entity.

For Hospital Credentialing. I consent to appear for an interview with the credentials committee, medical staff executive committee, or other representatives of the medical staff, hospital administration or the governing board, if required or requested. As a medical staff member, I pledge to provide continuous care for my patients. I have been informed of existing hospital bylaws, rules and regulations, and policies regarding the application process, and I agree that as a medical staff member, I will be bound by them.

Authorization of Investigation Concerning Application for Participation. I authorize the following individuals including, without limitation, the Entity, its representatives, employees, and/ or designated agent(s); the Entity s affiliated entities and their representatives, employees, and/ or designated agents; and the Entity s designated professional credentials verification organization (collectively referred to as Agents), to investigate information, which includes both oral and written statements, records, and documents, concerning my application for Participation. I agree to allow the Entity and/or its Agent(s) to inspect all records and documents relating to such an investigation.

Authorization of Third-Party Sources to Release Information Concerning Application for Participation. I authorize any third party, including, but not limited to, individuals, agencies, medical groups responsible for credentials verification, corporations, companies, employers, former employers, hospitals, health plans, health maintenance organizations, managed care organizations, law enforcement or licensing agencies, insurance companies, educational and other institutions, military services, medical credentialing and accreditation agencies, professional medical societies, the Federation of State Medical Boards, the National Practitioner Data Bank, and the Health Care Integrity and Protection Data Bank, to release to the Entity and/or its Agent(s), information, including otherwise privileged or confidential information, concerning my professional qualifications, credentials, clinical competence, quality assurance and utilization data, character, mental condition, physical condition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having a bearing on my qualifications for Participation in, or with, the Entity. I authorize my current and past professional liability carrier(s) to release my history of claims that have been made and/ or are currently pending against me. I specifically waive written notice from any entities and individuals who provide information based upon this Authorization, Attestation and Release.

Authorization of Release and Exchange of Disciplinary Information. I hereby further authorize any third party at which I currently have Participation or had Participation and/ or each third party s agents to release Disciplinary Information, as defined below, to the Entity and/ or its Agent(s). I hereby further authorize the Agent(s) to release Disciplinary Information about any disciplinary action taken against me to its participating Entities at which I have Participation, and as may be otherwise required by law. As used herein, Disciplinary Information means information concerning:

(I)any action taken by such health care organizations, their administrators, or their medical or other committees to revoke, deny, suspend, restrict, or condition my Participation or impose a corrective action plan; (ii) any other disciplinary action involving me, including, but not limited to, discipline in the employment context; or (iii) my resignation prior to the conclusion of any disciplinary proceedings or prior to the commencement of formal charges, but after I have knowledge that such formal charges were being (or are being) contemplated and/ or were (or are) in preparation.

Release from Liability. I release from all liability and hold harmless any Entity, its Agent(s), and any other third party for their acts performed in good faith and without malice unless such acts are due to the gross negligence or willful misconduct of the Entity, its Agent(s), or other third party in connection with the gathering, release and exchange of, and reliance upon, information used in accordance with this Authorization, Attestation and Release. I further agree not to sue any Entity, any Agent(s), or any other third

APPLICANTS INITIALS AND DATE (MMDD YYYY)

LHL234 REV.01/07

11 OF 20

Section III Standard Authorization, Attestation and Release continued

party for their acts, defamation or any other claims based on statements made in good faith and without malice or misconduct of such Entity, Agent(s) or third party in connection with the credentialing process. This release shall be in addition to, and in no way shall limit, any other applicable immunities provided by law for peer review and credentialing activities.

In this Authorization, Attestation and Release, all references to the Entity, its Agent(s), andor other third party include their respective employees, directors, officers, advisors, counsel, and agents. The Entity or any of its affiliates or agents retains the right to allow access to the application information for purposes of a credentialing audit to customers andor their auditors to the extent required in connection with an audit of the credentialing processes and provided that the customer andor their auditor executes an appropriate confidentiality agreement. I understand and agree that this Authorization, Attestation and Release is irrevocable for any period during which I am an applicant for Participation at an Entity, a member of an Entity s medical or health care staff, or a participating provider of an Entity. I agree to execute another form of consent if law or regulation limits the application of this irrevocable authorization. I understand that my failure to promptly provide another consent may be grounds for termination or discipline by the Entity in accordance with the applicable bylaws, rules, and regulations, and requirements of the Entity, or grounds for my termination of Participation at or with the Entity. I agree that information obtained in accordance with the provisions of this Authorization, Attestation and Release is not and will not be a violation of my privacy.

I certify that all information provided by me in my application is true, correct, and complete to the best of my knowledge and belief, and that I will notify the Entity and or its Agent(s) within 10 days of any material changes to the information I have provided in my application or authorized to be released pursuant to the credentialing process. I understand that corrections to the application are permitted at any time prior to a determination of Participation by the Entity, and must be submitted on-line or in writing, and must be dated and signed by me (may be a written or an electronic signature). I understand and agree that any material misstatement or omission in the application may constitute grounds for withdrawal of the application from consideration; denial or revocation of Participation; andor immediate suspension or termination of Participation. This action may be disclosed to the Entity andor its Agent(s).

I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release. I understand and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original.

SIGNATURE

NAME (PLEASE PRINT OR TYPE)

Last 4 digits of SSN or NPI (PLEASE PRINT OR TYPE)

DATE (MMDD YYYY)

Required Attachments or Supplemental Information Please attach hard copy or scanned documents of the following:

Copy of DEA or state DPS Controlled Substances Registration Certificate

Copy of other Controlled Dangerous Substances Registration Certificate(s)

Copy of current professional liability insurance policy face sheet, showing expiration dates, limits and applicants name

Copies of IRS W-9s for verification of each tax identification number used

Copy of workers compensation certificate of coverage, if applicable

Copy of CLIA certifications, if applicable

Copies of radiology certifications, if applicable

Copy of DD214, record of military service, if applicable

Reproduction of this form without any changes is allowed.

Notice About Certain Information Laws and Practices Pertaining to State Governmental Bodies (i.e. State Hospitals)

With few exceptions, you are entitled to be informed about the information that a state governmental body collects about you (i.e. a state hospital). Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself, including private information. However the state governmental body may withhold information for reasons other than to protect your right to privacy. Under section 559.004 of the Texas Government Code, you are entitled to request that the state governmental body correct information that it has about you that is incorrect. For information about the procedure and costs for obtaining information, please contact the appropriate state governmental body to which you have submitted this application.

LHL234 REV.01/07

12 OF 20

Texas Standardized Credentialing Application

At t a c h m e n t A Ot h e r Pr o f e s s i o n a l De g r e e s

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY

STATE/COUNTRY

POSTAL CODE

 

 

 

 

DEGREE

 

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

 

 

 

 

 

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY

STATE/COUNTRY

POSTAL CODE

 

 

 

 

DEGREE

 

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

 

 

 

 

 

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY

STATE/COUNTRY

POSTAL CODE

 

 

 

 

DEGREE

 

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

 

 

 

 

 

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY

STATE/COUNTRY

POSTAL CODE

 

 

 

 

DEGREE

 

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

 

 

 

 

 

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY

STATE/COUNTRY

POSTAL CODE

 

 

 

 

DEGREE

 

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

 

 

 

 

 

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY

STATE/COUNTRY

POSTAL CODE

 

 

 

 

DEGREE

 

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

 

 

 

 

 

OTHER PROFESSIONAL DEGREE

Issuing Institution:

ADDRESS

CITY

STATE/COUNTRY

POSTAL CODE

 

 

 

 

DEGREE

 

ATTENDANCE DATES(MM/YYYY TO MM/YYYY)

 

 

 

 

 

LHL234 REV.01/07

13 OF 20

Texas Standardized Credentialing Application

At t a c h m e n t B Ot h e r Po s t Gr a d u a t e Ed u c a t i o n

OTHER 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)

 

 

 

 

 

OTHER 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)

 

 

 

 

 

OTHER 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)

 

 

 

 

 

OTHER 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)

 

 

 

 

 

OTHER 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)

LHL234 REV.01/07

14 OF 20

Texas Standardized Credentialing Application

At t a c h m e n t C Ot h e r Wo r k Hi s t o r y

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

 

 

 

 

 

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

 

 

 

 

 

PREVIOUS PRACTICE/EMPLOYER NAME

 

START DATE/END DATE (MM/YYYY TO MM/YYYY)

 

 

 

ADDRESS

 

 

 

 

 

CITY

STATE/COUNTRY

POSTAL CODE

 

 

 

REASON FOR DISCONTINUANCE

 

 

 

 

 

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15 OF 20

Texas Standardized Credentialing Application

At t a c h m e n t D Ot h e r Cu r r e n t Ho s p i t a l Af f i l i a t i o n s

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?

 

 

 

 

 

 

 

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?

 

 

 

 

 

 

 

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?

 

 

 

 

 

 

 

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?

 

 

 

 

 

 

 

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?

 

 

 

 

 

 

 

 

 

 

LHL234 REV.01/07

16 OF 20

Texas Standardized Credentialing Application Attachment E Other Previous Hospital Affiliations

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

ADDRESS

CITY

FULL UNRESTRICTED PRIVILEGES?

Yes No

REASON FOR DISCONTINUANCE

STATE/COUNTRY

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

POSTAL CODE

WERE PRIVILEGES TEMPORARY?

Yes No

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

ADDRESS

CITY

 

STATE/COUNTRY

 

 

FULL UNRESTRICTED PRIVILEGES?

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

Yes

No

 

 

 

 

REASON FOR DISCONTINUANCE

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES

ADDRESS

POSTAL CODE

WERE PRIVILEGES TEMPORARY?

Yes No

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

CITY

FULL UNRESTRICTED PRIVILEGES?

Yes No

REASON FOR DISCONTINUANCE

STATE/COUNTRY

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

POSTAL CODE

WERE PRIVILEGES TEMPORARY?

Yes No

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

ADDRESS

CITY

 

STATE/COUNTRY

 

 

FULL UNRESTRICTED PRIVILEGES?

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

Yes

No

 

 

 

 

REASON FOR DISCONTINUANCE

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES

ADDRESS

POSTAL CODE

WERE PRIVILEGES TEMPORARY?

Yes No

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

CITY

FULL UNRESTRICTED PRIVILEGES?

Yes No

REASON FOR DISCONTINUANCE

STATE/COUNTRY

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

POSTAL CODE

WERE PRIVILEGES TEMPORARY?

Yes No

PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

ADDRESS

CITY

FULL UNRESTRICTED PRIVILEGES?

Yes No

REASON FOR DISCONTINUANCE

STATE/COUNTRY

TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)

POSTAL CODE

WERE PRIVILEGES TEMPORARY?

Yes No

LHL234 REV.01/07

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Texas Standardized Credentialing Application

At t a c h m e n t F Ot h e r Pr a c t i c e Lo c a t i o n s

Practice Location Information - Please answer the following questions for each practice location. Use Attachment F or make

PRACTICE LOCATION

copies of pages 6-7 as necessary.

 

 

 

 

of

TYPE OF SERVICE PROVIDED

 

 

 

 

 

Solo Primary Care

Solo Specialty Care

Group Primary Care

Group Single Specialty

Group Multi-Specialty

 

 

 

 

 

 

GROUP NAME/PRACTICE NAME TO APPEAR IN THE DIRECTORY

 

GROUP/CORPORATE NAME AS IT APPEARS ON IRS W-9

 

 

 

 

 

 

PRACTICE LOCATION ADDRESS

 

 

 

 

 

Primary

 

 

 

 

 

 

CITY

 

 

STATE/COUNTRY

 

POSTAL CODE

 

 

 

 

 

 

 

PHONE NUMBER

FAX NUMBER

E-MAIL

BACK OFFICE PHONE NUMBER

GROUP NUMBER CORRESPONDING TO TAX ID NUMBER

ARE YOU CURRENTLY PRACTICING AT THIS LOCATION?

Yes No

OFFICE MANAGER OR STAFF CONTACT

 

 

 

 

 

 

 

 

 

 

SITE-SPECIFIC MEDICAID NUMBER

 

TAX ID NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

GROUP NAME CORRESPONDING TO TAX ID NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

IF NO, EXPECTED START DATE? (MM/DD/YYYY)

 

DO YOU WANT THIS LOCATION LISTED IN THE

 

 

 

 

 

 

DIRECTORY?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

PHONE NUMBER

 

 

FAX NUMBER

 

 

 

 

 

 

 

 

 

 

CREDENTIALING CONTACT

ADDRESS

CITY

STATE/COUNTRY

POSTAL CODE

 

 

 

PHONE NUMBER

FAX NUMBER

E-MAIL

BILLING COMPANY'S NAME (IF APPLICABLE)

 

BILLING REPRESENTATIVE

 

 

 

ADDRESS

CITY

PHONE NUMBER

DEPARTMENT NAME IF HOSPITAL-BASED

 

STATE/COUNTRY

 

POSTAL CODE

 

 

 

 

 

FAX NUMBER

 

E-MAIL

 

 

 

 

 

 

 

CHECK PAYABLE TO

CAN YOU BILL ELECTRONICALLY?

 

 

 

Yes

No

 

 

 

 

 

HOURS PATIENTS ARE SEEN

 

 

 

Monday

No Office Hours

Morning:

Afternoon:

Evening:

Tuesday

No Office Hours

Morning:

Afternoon:

Evening:

Wednesday

No Office Hours

Morning:

Afternoon:

Evening:

Thursday

No Office Hours

Morning:

Afternoon:

Evening:

Friday

No Office Hours

Morning:

Afternoon:

Evening:

Saturday

No Office Hours

Morning:

Afternoon:

Evening:

Sunday

No Office Hours

Morning:

Afternoon:

Evening:

DOES THIS LOCATION PROVIDE 24 HOUR/7 DAY A WEEK PHONE COVERAGE?

 

 

 

Answering Service

Voice mail with instructions to call answering service

Voice mail with other instructions

None

 

 

 

 

 

 

THIS PRACTICE LOCATION ACCEPTS

 

 

 

 

 

all new patients

existing patients with change of payor

new patients with referral

new Medicare patients

new Medicaid patients

 

 

 

 

IF NEW PATIENT ACCEPTANCE VARIES BY HEALTH PLAN, PLEASE PROVIDE EXPLANATION.

 

 

 

 

 

 

 

 

 

 

PRACTICE LIMITATIONS

 

 

 

 

 

 

Male only

Female only

Age:

Other:

 

 

 

 

DO NURSE PRACTITIONERS, PHYSICIAN ASSISTANTS, MIDWIVES, SOCIAL WORKERS OR OTHER NON-PHYSICIAN PROVIDERS CARE FOR PATIENTS AT THIS PRACTICE LOCATION?

Yes No

If yes, provide the following information for each staff member:

 

 

 

 

 

 

 

 

 

NAME

 

 

PROFESSIONAL DESIGNATION

 

STATE & LICENSE NO.

 

 

 

 

 

 

NAME

 

 

PROFESSIONAL DESIGNATION

 

STATE & LICENSE NO.

 

 

 

 

 

 

 

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ATTACHMENT F (CONTINUED)

Practice Location Information - continued

NAME

PROFESSIONAL DESIGNATION

STATE & LICENSE NO.

 

 

 

NAME

PROFESSIONAL DESIGNATION

STATE & LICENSE NO.

 

 

 

NAME

PROFESSIONAL DESIGNATION

STATE & LICENSE NO.

 

 

 

NAME

PROFESSIONAL DESIGNATION

STATE & LICENSE NO.

 

 

 

NON-ENGLISH LANGUAGES SPOKEN BY HEALTH CARE PROVIDERS

ARE INTERPRETERS AVAILABLE?

Yes No If yes, please specify languages:

NON-ENGLISH LANGUAGES SPOKEN BY OFFICE PERSONNEL

DOES THIS PRACTICE LOCATION MEET ADA ACCESSIBILITY STANDARDS?

Yes No

WHICH OF THE FOLLOWING FACILITIES ARE HANDICAPPED ACCESSIBLE?

Building Parking Restroom Other:

DOES THIS LOCATION HAVE OTHER SERVICES FOR THE DISABLED?

Text Telephony-TTY American Sign Language-ASL Mental/Physical Impairment Services

0ther:

IS THIS LOCATION ACCESSIBLE BY PUBLIC TRANSPORTATION?

Bus Regional Train Other:

DOES THIS LOCATION PROVIDE CHILDCARE SERVICES?

Yes No

DOES THIS LOCATION QUALIFY AS A MINORITY BUSINESS ENTERPRISE?

Yes No

WHO AT THIS LOCATION HAVE THE FOLLOWING CURRENT CERTIFICATIONS? (PLEASE LIST ONLY THE APPLICANT'S CERTIFICATION EXPIRATION DATES.)

Basic Life Support

Advanced Trauma Life Support

Advanced Cardiac Life Support

Neonatal Advanced Life Support

Staff

Staff

Staff

Staff

Provider Exp:

Advanced Life Support in OB

Provider Exp:

Cardio-Pulmonary Resuscitation

Provider Exp:

Pediatric Advanced Life Support

Provider Exp:

Other (please specify)

Staff

Staff

Staff

Staff

Provider Exp:

Provider Exp:

Provider Exp:

Provider Exp:

DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE?

Yes

No

Laboratory Services; please list all Certificates of Participation (CLIA, AAFP, COLA, CAP, MLE):

DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE?

Yes

X-ray; please list all certifications:

 

No

OTHER SERVICES

Radiology Services

Allergy Injections

Age Appropriate Immunizations

Osteopathic Manipulations

Other:

EKG

Allergy Skin Tests

Flexible Sigmoidoscopy

IV Hydration /Treatments

Care of Minor Lacerations

Routine Office Gynecology

Tympanometry/Audiometry Tests

Cardiac Stress Tests

Pulmonary Function Tests

Drawing Blood

Asthma Treatments

Physical Therapies

PLEASE LIST ANY ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)

IS ANESTHESIA ADMINISTERED AT THIS PRACTICE LOCATION?

Yes No Please specify the classes or categories:

WHO ADMINISTERS IT?

Please check this box and complete and submit Attachment F if you have other practice locations.

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Texas Standardized Credentialing Application

At t a c h m e n t G Ma l p r a c t i c e Cl a i m s Hi s t o r y

INCIDENT DATE (MM/DD/YYYY)

DATE CLAIM WAS FILED (MM/DD/YYYY)

CLAIM/CASE STATUS

PROFESSIONAL LIABILITY CARRIER INVOLVED

ADDRESS

CITY

PHONE NUMBER

STATE/COUNTRY

POLICY NUMBER

POSTAL CODE

AMOUNT OF AWARD OR SETTLEMENT & AMOUNT PAID

$

$

METHOD OF RESOLUTION Dismissed

Judgment for Defendant(s)

DESCRIPTION OF ALLEGATIONS

Settled (with prejudice)

Judgment for Plaintiff(s)

Settled (without prejudice)

Mediation or Arbitration

WERE YOU PRIMARY DEFENDANT OR CO-DEFENDANT?

DESCRIPTION OF ALLEGED INJURY TO THE PATIENT

NUMBER OF OTHER CO-DEFENDANTS

YOUR INVOLVEMENT (ATTENDING, CONSULTING, ETC.)

TO THE BEST OF YOUR KNOWLEDGE, IS THIS CASE INCLUDED IN THE NATIONAL PRACTITIONER DATA BANK (NPDB)?

Yes No

 

 

 

INCIDENT DATE (MM/DD/YYYY)

DATE CLAIM WAS FILED (MM/DD/YYYY)

 

 

PROFESSIONAL LIABILITY CARRIER INVOLVED

 

 

 

CLAIM/CASE STATUS

ADDRESS

CITY

PHONE NUMBER

STATE/COUNTRY

POLICY NUMBER

POSTAL CODE

AMOUNT OF AWARD OR SETTLEMENT & AMOUNT PAID

$

$

METHOD OF RESOLUTION Dismissed

Judgment for Defendant(s)

DESCRIPTION OF ALLEGATIONS

Settled (with prejudice)

Judgment for Plaintiff(s)

Settled (without prejudice)

Mediation or Arbitration

WERE YOU PRIMARY DEFENDANT OR CO-DEFENDANT?

DESCRIPTION OF ALLEGED INJURY TO THE PATIENT

NUMBER OF OTHER CO-DEFENDANTS

YOUR INVOLVEMENT (ATTENDING, CONSULTING, ETC.)

TO THE BEST OF YOUR KNOWLEDGE, IS THIS CASE INCLUDED IN THE NATIONAL PRACTITIONER DATA BANK (NPDB)?

Yes No

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