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The Louisiana Credentialing Application form serves as a comprehensive tool for healthcare providers to gather and submit essential information for credentialing purposes. This form requires detailed personal and professional data, ensuring that every section is filled completely. It begins by collecting general information about the applicant, including personal identification details and educational qualifications. Furthermore, applicants must indicate their primary practice locations, providing specific information such as the name of the institution, physical addresses, contact numbers, types of practice, and whether they are accepting new patients. A focus on accessibility is also included, ensuring compliance with the Americans with Disabilities Act (ADA) and detailing any services available for individuals with disabilities. The form goes on to require details about specialties and certifications, promoting the need for attached documents to verify professional qualifications. By explicitly outlining responsibilities and necessary information, this application facilitates a streamlined credentialing process crucial for maintaining standards in healthcare delivery.

Louisiana 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 Louisiana Credentialing Application PDF Form

Form Characteristics

Fact Name Description
Purpose The Louisiana Credentialing Application form is designed to collect essential information from healthcare providers to ensure they meet state requirements for practicing medicine.
Completion Requirements All sections of the application must be filled out completely. Responses like “See C.V.” are not considered acceptable.
Governing Laws This application is regulated under Louisiana state law, specifically the Louisiana Medical Practice Act (RS 37:1261 et seq.).
Supporting Documents Applicants must attach required documents as specified on page 10 of the application. It's crucial to refer to this list to avoid delays.
Residency Requirements Providers must provide proof of residency or practice location within Louisiana, demonstrating their commitment to serving the community.
Practice Location Information Multiple practice locations can be provided. For any additional locations beyond four, applicants must attach separate sheets with information as requested.
Confidential Information Personal information such as Social Security Number and date of birth is collected to verify identity and maintain provider records securely.

Guidelines on Utilizing Louisiana Credentialing Application

Completing the Louisiana Credentialing Application form is a crucial step in your professional journey. Once you have filled it out, you will need to gather the required documents listed on page ten and submit everything together to the appropriate agency. Ensure accuracy in your responses, as incomplete forms may delay processing.

  1. General Information: Start by filling in your last name, suffix, first name, and middle name. Select your gender, degree, and include any other names you have been known by.
  2. Contact Information: Provide your home address, phone numbers, email address, social security number, date of birth, birth place, race/ethnicity, and provider numbers.
  3. Primary Practice Location: Enter the institution name if applicable, the office manager’s name, the tax identification number, and the effective date of your provider status at this location. Include the group NPI and the physical address details.
  4. Office Details: Fill out the office email, website, phone numbers, and billing addresses. Provide the contact person's information and specify the correspondence and medical records address details.
  5. Practice Information: Indicate the type of practice and hours of operation. Specify if you practice full-time, part-time, or other along with the languages spoken at the location.
  6. Patient Acceptance: Indicate if you are accepting new patients, specify age groups treated, and answer questions regarding accessibility for disabled individuals and compliance with ADA requirements.
  7. Emergency Arrangements: Provide the emergency after-hours number and details for 24/7 coverage and covering physician contact information.
  8. Additional Practice Locations: If applicable, repeat the relevant details for up to four practice locations, using additional sheets as necessary.
  9. Specialty & Certification: Attach current certification copies. Indicate your type of provider, primary and secondary specialty, and the boards you are certified by.
  10. Directory Information: Mark whether the specialties and subspecialties are practiced at each location and if they are to be noted in the directory.
  11. PHO/IPA Affiliations: List any relevant affiliations and participation dates in PHO’s or IPA’s.

What You Should Know About This Form

What is the purpose of the Louisiana Credentialing Application form?

The Louisiana Credentialing Application form is designed for healthcare providers seeking to establish or maintain their credentials in Louisiana. This comprehensive application collects essential information needed by healthcare organizations to verify a provider's qualifications, experience, and operational capacity. Completing this form accurately is crucial for obtaining privileges for practice within various facilities across the state.

Who needs to complete this application?

This application must be completed by healthcare professionals including but not limited to physicians (MDs and DOs), dentists (DDS and DMD), and specialists wishing to affiliate with hospitals or managed care organizations. If a provider practices in multiple locations, they will need to provide details for each site on the form.

Are there specific documents required to submit with the application?

Yes, there is a list of required documents that must accompany the completed application. These documents typically include copies of certifications, licenses, and identification numbers, among others. All sections of the application must be filled out completely; simply referring to a Curriculum Vitae (C.V.) is not acceptable.

What should I do if I have more than four practice locations?

If a provider practices at more than four locations, additional sheets with the required information for each extra location should be attached to the application. It is essential to reference the specific questions being answered to ensure clarity and proper organization of information.

Can I use a pen to complete the application?

It is strongly recommended to type or print the application in black ink. This helps maintain the legibility of the form and ensures that all information can be clearly read when reviewed by credentialing committees.

How should I answer questions about my practice type and specialties?

When answering about practice type and specialties, select the option that best describes your situation from the provided choices, such as “Solo,” “Multi-specialty Group,” or “Hospital-employed.” You should also specify your primary specialty and any additional specialties you're certified in. Providing accurate information helps streamline the credentialing process.

What if I need to update my information after submission?

If there are any changes after submitting your application, it’s critical to inform the credentialing office as soon as possible. Changes in practice location, contact information, or clinical privileges can affect your credentialing status, so timely communication of these updates is key.

Is there a deadline for submitting the Louisiana Credentialing Application?

While specific deadlines may vary depending on the healthcare organization or facility, it is wise to submit the application as early as possible to prevent any delays in the credentialing process. Keeping in touch with the credentialing office can provide clarity on deadlines and necessary submissions.

What happens after I submit the application?

After the application is submitted, the credentialing office will review it for completeness and accuracy. Verification of the provided information will take place, which may include background checks, checking references, and confirming licenses and certifications. The process might take several weeks, so patience is necessary as the application is processed and evaluated.

Common mistakes

Completing the Louisiana Credentialing Application form can be straightforward, but many individuals still make common mistakes. One frequent error is not filling out all sections completely. Every section must be addressed. Simply writing "See C.V." is not an acceptable response. This omission can lead to delays. It’s crucial to provide all necessary details to ensure your application is processed smoothly.

An additional mistake occurs when applicants fail to match names and numbers accurately. For instance, the Tax Identification Number (TIN) and the Employer Identification Number (EIN) must correspond precisely with IRS records. Any discrepancies can raise red flags, complicating the review process. Always double-check this information to avoid unnecessary complications.

Inaccuracies related to contact information are also common. Providing an outdated email or phone number can hinder communications. If the credentialing agency cannot reach you, it can delay your application. Ensure that all contact details are current and correct, as this can facilitate quicker responses and resolutions to any issues that may arise.

Another significant mistake is neglecting to include required documents. The application directions specify a list of mandatory documents on page 10. Skipping this step can result in application rejection. Review the requirements thoroughly before submitting your form, and ensure that everything is included.

Some applicants mistakenly select the wrong type of practice option. This can lead to misunderstandings about your services and may affect your potential patient roster. Choose the appropriate practice type carefully. Misclassifications can complicate the review process and ultimately impact your ability to practice.

Inconsistent or incomplete responses about languages spoken can also hinder the application process. Including all relevant languages is vital, especially in a diverse state like Louisiana. The ability to communicate with patients in their preferred language is essential for quality care, and any misunderstandings here could affect your practice's accessibility.

Additionally, many applicants forget to specify their practice hours clearly. Leaving this section blank—or providing vague hours—can lead to confusion. Clear, specific hours improve your accessibility and help credentialing agencies understand how you operate.

Furthermore, failing to indicate whether the facility is compliant with the Americans with Disabilities Act (ADA) can be problematic. This information is particularly important for ensuring inclusiveness. Indicate clearly whether or not your location meets ADA standards.

Finally, neglecting to review the entire application for errors before submission is a common oversight. Even minor typos can create significant bureaucratic delays. Reread your application and check for anything that could be misinterpreted or misunderstood. A final review can save you a lot of time and hassle.

Documents used along the form

The Louisiana Credentialing Application form is a detailed document crucial for healthcare providers seeking to practice in the state. Submitting this form often requires accompanying documents that support the application. These additional forms ensure a thorough review of the applicant's qualifications and credentials.

  • Curriculum Vitae (CV): A comprehensive summary of the individual's education, work experience, certifications, and professional affiliations, providing context about the applicant's career and achievements.
  • Board Certification Documentation: Proof of certification from relevant professional boards, showcasing the applicant's qualifications and specialties in their field.
  • Professional Liability Insurance Certificate: Evidence of current liability insurance coverage, essential for ensuring financial protection against claims of malpractice.
  • Drug Enforcement Administration (DEA) Certificate: This document certifies that the provider is authorized to prescribe controlled substances, critical for many medical practices.
  • Malpractice Claims History: A report detailing any prior malpractice claims, which lenders and hospitals may require to assess risk and suitability for credentialing.
  • Background Check Consent Form: A form granting permission for a background check, a standard practice for verifying the applicant's criminal history and professional conduct.

Providing these documents along with the Louisiana Credentialing Application can enhance the application process, ensuring compliance with state regulations and fostering a smoother evaluation. Proper preparation is key to a successful credentialing experience.

Similar forms

  • Credentialing Application for Healthcare Professionals: This document, used by various healthcare organizations, collects professional and background information to verify the qualifications of healthcare providers.

  • Medical Staff Application: Hospitals and medical facilities often use this to assess applicants for medical staff privileges, requiring similar details about qualifications and practice history.

  • Provider Enrollment Forms: These forms are utilized by Medicaid and Medicare to enroll healthcare providers, mirroring the requirement for personal, professional, and demographic information found in the Louisiana form.

  • State Licensing Application: Applicants for a medical license in any state must submit extensive personal and educational details, resembling the thoroughness of the Louisiana Credentialing Application.

  • Privileging Application: Similar to credentialing, privileging applications focus on specific procedures a healthcare provider may perform, often including overlapping information about professional history and training.

  • Insurance Credentialing Form: This document is necessary for providers to be authorized to bill insurance companies, requiring detailed information about providers' qualifications and practice scope.

  • Joint Commission Application: Healthcare institutions seeking accreditation from the Joint Commission must complete an application that gathers data comparable to that in the Louisiana Credentialing Application.

Dos and Don'ts

When filling out the Louisiana Credentialing Application form, careful attention to detail is essential. Here are ten important do's and don'ts to guide you through the process.

  • Do complete all sections in full. Incomplete sections may delay your application.
  • Don't use shorthand or phrases like “See C.V.”. Each question requires a complete answer.
  • Do use black ink when typing or printing your application to ensure readability.
  • Don't leave any questions unanswered, even if the information seems trivial.
  • Do ensure that your Tax Identification Number matches exactly with IRS records.
  • Don't forget to attach any necessary documents as instructed in the application.
  • Do specify all locations where you provide services if you have more than four.
  • Don't assume that a second practice location is optional if it applies to you.
  • Do check your spelling and grammar. Errors can reflect poorly on you.
  • Don't underestimate the importance of typing or printing clearly; legibility is crucial.

Misconceptions

Here is a list of common misconceptions about the Louisiana Credentialing Application form, along with explanations to clarify each one.

  • Misconception 1: Only physicians need to complete the application.

    • This form is for various healthcare providers, including dentists and nurse practitioners. It is not limited to physicians.

  • Misconception 2: Informal notes like "See C.V." are acceptable in responses.

    • Response to any section must be complete. Informal notes are not accepted; every relevant detail must be filled out directly in the application.

  • Misconception 3: You can skip optional sections without any issues.

    • While some sections are marked optional, it's best to provide as much information as possible, particularly in areas like languages spoken or race/ethnicity, to ensure a complete application.

  • Misconception 4: You can submit the application without your NPI or Medicare provider numbers.

    • Both NPI and Medicare provider numbers are required. Failing to include them could delay your application process.

  • Misconception 5: The application can be filled out in any color of ink.

    • The application specifically requests you use black ink or type your responses. Following these directions is essential for clarity.

  • Misconception 6: It’s enough to provide only one practice location on the form.

    • The application requests details for multiple locations if applicable. If you have more than four, be sure to attach additional sheets.

  • Misconception 7: You don’t need to attach any documents with your application.

    • Required documents must be attached. Make sure to refer to the checklist provided on page 10 to avoid missing anything significant.

  • Misconception 8: Completing the application guarantees approval.

    • Filling out the application correctly does not guarantee approval. It is only the first step in the credentialing process.

  • Misconception 9: You can leave the emergency contact fields blank.

    • Providing an after-hours emergency contact is necessary. This ensures patients can reach a healthcare provider when needs arise outside standard office hours.

Key takeaways

  • Complete All Sections: Ensure that every section of the Louisiana Credentialing Application form is filled out completely. Leaving any part blank can lead to delays or rejection of your application.
  • Use Clear and Legible Writing: It is advised to type or print in black ink. Clarity is essential to avoid misunderstandings or errors in your application.
  • References and Attachments: If additional space is needed or you have more than four practice locations to list, attach separate sheets instead of abbreviating responses or using "See C.V."
  • Document Requirements: Familiarize yourself with the list of required documents outlined on page 10 of the application. Ensure that you include all necessary paperwork to support your application.
  • Practice Location Information: Provide accurate and detailed information for each practice location. This includes the name of the practice, address, contact details, and hours of operation.
  • Accessibility Information: Be prepared to specify whether your practice location meets the Americans with Disabilities Act (ADA) requirements and whether it offers handicapped access and services for disabled individuals.

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