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The Louisiana Standardized Credentialing Application form serves a crucial role in the credentialing process for healthcare providers in the state. It requires comprehensive information about the applicant, including personal details like name, contact information, and professional qualifications—specifically, their medical degree and experience. An applicant must provide their primary practice location and may indicate multiple locations if necessary. Important components include the verification of affiliations with healthcare institutions and any hospital or organization where they practice. The form also delves into the type of practice, whether it be solo or group-based, and asks about the acceptance of new patients, types of services provided, and compliance with Americans with Disabilities Act (ADA) requirements. Furthermore, applicants must outline their office hours and accessibility features to ensure all patients can receive care. By demanding such detailed disclosures, the form aims to establish a clear picture of a healthcare provider's qualifications and scope of practice, ultimately supporting a more streamlined and transparent credentialing process.

La Standardized Credentialing Application 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-employedHealthplan/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-employedHealthplan/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

Get La Standardized Credentialing Application PDF Form

Form Characteristics

Fact Description
Form Purpose The Louisiana Standardized Credentialing Application is used to gather essential details about healthcare providers for credentialing purposes.
Filling Instructions Applicants must complete all sections fully in black ink or type. Abbreviations like "See C.V." are not acceptable.
Governing Law This form follows the regulations outlined in Louisiana's Administrative Code for credentialing healthcare providers.
Accessibility Compliance The application includes questions to ensure the practice complies with the Americans with Disabilities Act (ADA) standards.

Guidelines on Utilizing La Standardized Credentialing Application

Completing the Louisiana Standardized Credentialing Application requires attention to detail. It is essential to fill out all sections thoroughly; incomplete applications may lead to delays. Follow the step-by-step instructions below to ensure all necessary information is accurately documented.

  1. Begin by entering your General Information:
    • Last Name
    • Suffix
    • First Name
    • Middle Name
    • Gender (select Male or Female)
    • Degree (select appropriate option)
    • Any other name (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
  2. Complete details for your 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
    • Physical Address, City, State, Zip Code
    • Office Email, Office Website
    • Main Phone Number, Appointment Phone Number, Fax Number
    • Billing Address details
    • Correspondence Address details
    • Medical Records Address details
    • Type of Practice
    • Office Hours
    • Practice details (full-time/part-time, other specifications)
    • Languages spoken (other than English)
  3. Indicate the Accepting Patients status:
    • Specify if accepting new patients
    • List age groups treated
    • Specify if PAs/nurse/etc. are used
    • Details on wheelchair/handicap access
    • Emergency After Hours Number
  4. If applicable, repeat the steps for your Second, Third, and Fourth Practice Locations as needed.
  5. Provide your Specialty & Certification information:
    • Type of Provider
    • Primary, Second, and Third Specialists with board certification details
  6. Finish with Directory Information:
    • Check specialties for each location
  7. Finally, list any PHO / IPA Affiliations you have.

With the application filled out, carefully review your responses for completeness and accuracy before submission. Be sure to attach any required documents as indicated on the application. This will help to expedite the credentialing process, ensuring a smoother path forward.

What You Should Know About This Form

What is the La Standardized Credentialing Application form?

The La Standardized Credentialing Application form is a comprehensive document that healthcare providers in Louisiana must complete to ensure they are credentialed by health plans and medical facilities. It gathers essential information about the provider’s identity, practice locations, specialties, and certifications. Completing this form accurately is crucial for timely approval and compliance with healthcare regulations.

How should I fill out the application form?

When filling out the application, use black ink or type your responses to ensure clarity. It's important to complete every section of the form fully; using “See C.V.” as a reference is not acceptable. If your responses require more space, attach additional sheets and clearly indicate which question you're answering. Reviewing the required documents list on page 10 is also essential to ensure you submit everything needed.

What information is required in the General Information section?

This section requires personal details such as your full name, gender, degree(s), and any other names you may have used. Additional essential information includes your Social Security Number, date of birth, race/ethnicity (optional), and various identification numbers like NPI and Medicare Provider Number. This data helps verify your identity and credentials during the approval process.

Can I list multiple practice locations on the form?

Yes, the application allows for multiple practice locations. You can provide details for up to four locations directly on the form. If you have more than four, attach additional sheets that include the same information format. Make sure to include practice type, office hours, and whether you are accepting new patients at each location.

What if I have more certifications than the form allows?

The form provides space to list multiple specialties and certifications recognized by national certification bodies. If you hold more certifications than can be listed on the application, attach additional documentation outlining these certifications. Ensure you clearly reference the relevant section or question so the reviewing committee can easily locate the information.

What types of practices are recognized in the application?

In the application, providers can categorize their practice as solo, multi-specialty group, single specialty group, hospital-based, hospital-employed, or health plan/payor-owned. Selecting the correct type is vital because it affects how your credentials will be viewed by health plans and other organizations.

Is there a deadline for submitting the application?

While the application itself does not specify a universal deadline, submission timelines can vary by health plans or facilities you are applying to. Therefore, it is advisable to check the specific requirements of each organization you wish to credential with. Timely submission enhances your chances of quick approval, allowing you to serve patients without unnecessary delays.

Common mistakes

Filling out the Louisiana Standardized Credentialing Application form requires careful attention to detail. Many applicants fall into common pitfalls that can lead to delays or even denials in their credentialing process. Understanding these mistakes can help ensure a smoother experience.

One frequent error occurs with incomplete sections. The form explicitly states that all sections must be completed in their entirety. Leaving any section unanswered or simply writing “See C.V.” is not acceptable. This can set back the application as the reviewing body will require the requested details to proceed. Always take a moment to review each section before submitting, as thoroughness is key.

Another mistake involves inconsistencies in information provided. For example, the Tax Identification Number (TIN) or the National Provider Identifier (NPI) must match IRS records exactly. Any discrepancy can raise red flags and potentially slow down the approval process. It’s advisable to double-check all numbers and names against official documents to avoid confusion later on.

Many applicants also fail to attach necessary documentation. Some forms might require specific certifications or proof of specialty. Be sure to refer to the list of required documents and include everything requested. A missing document could delay the process or result in an outright rejection of the application.

Providing outdated or inaccurate contact information poses yet another common challenge. It is crucial to ensure that the address, phone numbers, and email addresses listed are current and correct. Incorrect contact details can hinder communication and lead to missed opportunities to rectify issues as they arise.

Failing to provide sufficient details regarding practice locations is another area of concern. If a provider practices at more than four locations, it is essential to attach additional sheets, ensuring that each location is documented correctly. Overlooking this requirement can lead to incomplete applications, which may be returned for revision.

Additionally, applicants sometimes underestimate the importance of complete responses regarding practice facilities. Questions about wheelchair access or other accommodations should be answered thoroughly. Misrepresenting the accessibility of a facility may not only reflect poorly during the credentialing process but might also lead to legal ramifications in the future.

In conclusion, navigating the Louisiana Standardized Credentialing Application form can seem daunting. However, by being aware of these common mistakes, applicants can take proactive steps to ensure their application is complete and accurate, thereby increasing the likelihood of a successful credentialing experience.

Documents used along the form

When completing the Louisiana Standardized Credentialing Application form, various additional documents often accompany it. These documents help verify the information provided and support the credentialing process. Below is a brief overview of the most common forms and documents used alongside the application.

  • Curriculum Vitae (C.V.): This document outlines your professional history, including education, training, work experience, and professional affiliations. A complete C.V. is essential for providing a comprehensive view of your qualifications.
  • Medical Licenses: Copies of medical licenses are needed to confirm that you are legally authorized to practice medicine in the state. Any relevant specialties or additional certifications should also be included.
  • Malpractice Insurance Documentation: Proof of malpractice insurance coverage is required. This document provides evidence of your insurance policies, ensuring that you are protected against claims of negligence.
  • National Provider Identifier (NPI) Confirmation: A confirmation of your NPI is necessary for identifying healthcare providers in the United States. This number is essential for billing and administrative tasks within the healthcare system.
  • Continuing Medical Education (CME) Certificates: Providing documentation of completed CME courses can demonstrate your commitment to maintaining and enhancing your medical knowledge and skills.

Submitting these documents along with your application will help streamline the credentialing process. Ensure that everything is accurate and up-to-date, as this can significantly impact your approval timeline.

Similar forms

  • National Practitioner Data Bank (NPDB) Self-Query Request Form: Similar to the Louisiana Standardized Credentialing Application, this form requires personal and professional information to confirm that no disciplinary actions have been taken against the provider.
  • Credentialing Application for Medical Staff: Hospitals often utilize this application to gather similar data about a physician's qualifications, practice history, and specialties.
  • Privileging Application: This document outlines the specific procedures a physician can perform at a healthcare facility. It shares many of the same personal and professional details as the Louisiana application.
  • Medicare Enrollment Application (CMS-855): Required for healthcare providers to enroll in Medicare, this form includes detailed information about the provider’s practice location and specialties, akin to the Louisiana Standardized Credentialing Application.
  • State Medical License Application: Like the Louisiana form, this document requests comprehensive background information and verification of qualifications for medicine practice within a specific state.
  • Health Insurance Credentialing Application: Insurance companies need this application to assess a provider's eligibility to participate in their networks. It includes similar professional history and qualifications.
  • Direct Access Credentialing Application: Used for direct access providers, this form captures both demographic and practice information, paralleling the content required in the Louisiana application.
  • Clinical Privileges Application: This document requests specific practice and procedure information to determine a provider’s abilities and appropriate privileges, mirroring the credentialing needs of the Louisiana form.
  • Medical Staff Bylaws Membership Application: Similar to the credentialing application, this form collects personal, educational, and professional data to verify a physician’s qualifications for hospital membership.

Dos and Don'ts

When filling out the Louisiana Standardized Credentialing Application form, consider the following guidelines:

  • Complete all sections of the form. Do not write "See C.V." as a response.
  • Use black ink and type or print clearly to ensure readability.
  • Attach additional sheets if you need more space, and make sure to reference the corresponding question.
  • Double-check that all information matches with IRS documentation for accuracy.

Additionally, avoid the following common mistakes:

  • Leaving any section blank; all information must be provided.
  • Providing false or outdated information, which could lead to delays.
  • Ignoring the requirement for required documents outlined on page 10.
  • Neglecting to indicate your practice's accessibility options, if relevant.

Misconceptions

  • All sections of the form can be left blank if not applicable. This is a common misconception. In reality, every section must be completed in its entirety. Not providing information, such as writing "See C.V." in place of answers, is not acceptable.
  • The application does not require supporting documents. This is incorrect. A list of required documents is provided on page 10 of the instructions. Submitting the application without these documents may delay processing.
  • Practitioners can submit an incomplete form and provide details later. This is false. All the information must be accurate and complete at the time of submission for the application to be considered.
  • Only new applicants need to fill out the entire application. This is a misconception. Existing practitioners who are reapplying or updating their information must also complete all sections of the form fully.

Key takeaways

When filling out the Louisiana Standardized Credentialing Application, key considerations include the following:

  • Accuracy is essential: Ensure that all information is precise and complete. Avoid phrases like "see C.V." as they do not suffice for any sections.
  • Necessary documentation: Familiarize yourself with the required documents listed on page 10 of the application. Having these ready will expedite the process.
  • Multiple locations: If you have more than four practice locations, prepare additional sheets with the same structure and information required in the application.
  • Accessibility compliance: Be prepared to provide information on the accessibility of your practice locations according to the Americans with Disabilities Act (ADA). This includes physical access and available services for disabled individuals.

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