Texas Credentialing Application PDF Details

Credentialing is the process by which insurance networks, healthcare organizations, and hospitals verify the qualifications of a healthcare provider. This typically includes reviewing a provider's completed education, training, residency, licenses, and any certifications. It's a means of assuring that a provider is qualified and competent to care for patients.

All information provided must be accurate. Misrepresentations or false statements can result in serious consequences, including denial of credentialing, loss of licensure, or legal action.

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 Name Texas Credentialing Application
Form Length 20 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 5 min
Other names texas standard credentialing application pdf, texas credentialing, texas standardized application for p, standardized texas form pdf

Form Preview Example

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

 

(Please type or print)

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

 

 

 

 

 

 

Program successfully completed

 

ATTENDANCE DATES (MM/YYYY TO MM/YYYY)

 

 

 

 

 

 

 

 

 

PROGRAM DIRECTOR

 

 

CURRENT PROGRAM DIRECTOR (IF KNOWN)

 

 

 

 

 

 

POST-GRADUATE EDUCATION

 

 

SPECIALTY

 

Internship

Residency

Fellowship

Teaching Appointment

 

 

 

 

 

 

 

INSTITUTION

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

CITY

 

 

STATE/COUNTRY

POSTAL CODE

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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

 

 

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

 

 

LICENSE TYPE

LICENSE NUMBER

 

 

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

 

 

LICENSE TYPE

LICENSE NUMBER

 

 

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

 

 

DEA Number:

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

 

 

 

DPS Number:

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

 

 

 

OTHER CDS (PLEASE SPECIFY)

NUMBER

 

 

ORIGINAL DATE OF ISSUE (MM/DD/YYYY)

EXPIRATION DATE (MM/DD/YYYY)

 

 

STATE OF REGISTRATION

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?

ARE YOU A PARTICIPATING MEDICAID PROVIDER?

Yes

No

Medicare Provider Number:

Yes No

Medicaid Provider Number:

 

 

 

ECFMG ISSUE DATE (MM/DD/YYYY)

EDUCATIONAL COUNCIL FOR FOREIGN MEDICAL GRADUATES (ECFMG)

 

 

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)

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) 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

ADDRESS

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

CITY

STATE/COUNTRY

PREVIOUS PRACTICE/EMPLOYER NAME

ADDRESS

POSTAL CODE

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

CITY

STATE/COUNTRY

POSTAL CODE

REASON FOR DISCONTINUANCE

PREVIOUS PRACTICE/EMPLOYER NAME

ADDRESS

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

CITY

STATE/COUNTRY

POSTAL CODE

REASON FOR DISCONTINUANCE

PREVIOUS PRACTICE/EMPLOYER NAME

ADDRESS

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

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 – 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.

 

 

 

IF YOU DO NOT HAVE ADMITTING PRIVILEGES, WHAT ADMITTING ARRANGEMENTS DO YOU HAVE?

 

DO YOU HAVE HOSPITAL PRIVILEGES?

 

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

ADDRESS

AFFILIATION DATES (MM/YYYY TO MM/YYYY)

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.

1NAME/TITLE

PHONE NUMBER

ADDRESS

CITY

STATE/COUNTRY

POSTAL CODE

LHL234 Rev.01/07

4 of 20

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:

 

 

LHL234 Rev.01/07

5 of 20

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

PRACTICE LOCATION

make 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

SITE-SPECIFIC MEDICAID NUMBER

TAX ID NUMBER

 

 

 

 

 

 

 

GROUP NUMBER CORRESPONDING TO TAX ID NUMBER

GROUP NAME CORRESPONDING TO TAX ID NUMBER

 

 

 

 

 

 

DO YOU WANT THIS LOCATION LISTED IN THE

ARE YOU CURRENTLY PRACTICING AT THIS LOCATION?

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

Yes No

 

 

DIRECTORY?

Yes

No

 

 

 

 

 

OFFICE MANAGER OR STAFF CONTACT

 

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

STATE/COUNTRY

POSTAL CODE

PHONE NUMBER

FAX NUMBER

E-MAIL

DEPARTMENT NAME IF HOSPITAL-BASED

CHECK PAYABLE TO

 

 

HOURS PATIENTS ARE SEEN

CAN YOU BILL ELECTRONICALLY?

Yes No

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

 

 

Other:

 

 

 

Male only

 

Female only

Age:

 

 

 

 

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

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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

No

 

X-ray; please list all certifications:

 

 

 

 

 

 

 

 

 

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?

2

Yes

No

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

No

 

Yes

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

4Have 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?

8

Yes

No

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

 

 

Yes

No

9Have 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, disqualified 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

16Have 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

19Have 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

22Do 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 reasonable 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

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