The Louisiana Credentialing Application form is a comprehensive document designed for healthcare professionals seeking to provide medical services within the state of Louisiana. It requires detailed information about the applicant's general background, practice locations, accessibility features, and specialty certifications to ensure a thorough evaluation process. Filling out this form accurately and completely is crucial for successful credentialing. Click the button below to get started on your application.
Filled with detailed sections, the Louisiana Credentialing Application form is a comprehensive document designed for medical professionals seeking to formalize their credentials within the state. It requires applicants to input their personal details, professional qualifications, practice information, and more, all to be written clearly in black ink. The form insists on complete answers, eschewing references to external documents like CVs for the information it solicits. With space dedicated to the specifics of up to four practice locations—including whether these sites meet ADA accessibility standards, the types of practice (solo, group, hospital-based, etc.), and patient demographics served—this application covers a broad scope of professional practice details. Moreover, it delves into service accessibility, requesting information on languages spoken, the availability of services for the disabled, and emergency coverage arrangements. Applicants are also asked about their specialty and certification, affiliation with professional healthcare organizations (PHOs/IPAs), and how they would like their specialties to be listed in directories, underscoring the form’s role in both credential verification and public-facing healthcare provider information. The form comes complete with a directive for attaching necessary documents, making it both a thorough vetting tool and resource for patients seeking care.
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
Office Email
Office Website
Main Phone Number
Appointment Phone
Fax Number
Billing Address (Where you want payments sent)
Contact Person
Phone Number
Billing Email
Correspondence Address
(Where you want communications sent)
Correspondence Email
Medical Records Address
(Where you want medical record requests sent)
Medical Records Email
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
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
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
Offers services for the disabled: Text Telephony (TTY): Yes No
American Sign Language: Yes No
Mental/Physical Impairment Services: Yes No
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
Page 2 of 10
SECOND PRACTICE LOCATION CONTINUED
Does the office offer handicapped access for: Building: Yes No
Accessible by public transportation:
Bus: Yes No Courier Service: Yes No
THIRD PRACTICE LOCATION
Hospital-employed
Healthplan/Payor-owned
Page 3 of 10
THIRD PRACTICE LOCATION CONTINUED
Accessible by public transportation: Bus: Yes No Courier Service: Yes No Other:
Offers services for the disabled:
Text Telephony (TTY): Yes No
FOURTH PRACTICE
LOCATION
(If you have more than four locations, attach additional sheets with the following information.)
Page 4 of 10
FOURTH PRACTICE LOCATION CONTINUED
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:
Third Specialty:
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
Directory
Sub-specialty
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:
Zip
Degree
Year of Graduation
Dates Attended (MO/YR):
From: _______ to _______
Internship: Institution Name
Type of Training
University Affiliation
Completed
Yes No
Residency: Institution Name
Type of Residency
Clinical
Research
Completed:
Yes
No
Fellowship: Institution Name
Specialty Field
Type of Fellowship
Subspecialty Fields
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
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:
(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
Street Address
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?
Are you self-insured in accordance with the Louisiana Medical Malpractice Act?
Has current liability insurance carrier required exclusion of any procedures from insurance
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
Filling out the Louisiana Credentialing Application form is a detailed process that requires your full attention. It's important to answer each question comprehensively, using black ink for handwritten applications or a clear font if typing. Before beginning, gather all necessary documents listed on page 10 of the form, ensuring you have the most current and accurate information available. Don't hesitate to attach additional sheets if more space is needed, clearly indicating the question number each answer corresponds with.
After completing the Louisiana Credentialing Application form in its entirety, submit it according to the instructions provided by the agency or institution requesting it. It's important to keep a copy of the completed form and any accompanying documents for your own records. Timely submission and careful completion of the application are crucial for a smoothly processed application.
The Louisiana Standardized Credentialing Application is a comprehensive form designed for healthcare providers in Louisiana to provide necessary credentials and practice information. It is required for physicians and other healthcare practitioners who wish to be credentialized or re-credentialed with hospitals, health plans, and other healthcare entities within the state. The application collects general information, practice details, and documentation of qualifications.
The application should be typed or printed in black ink. It's crucial to complete all sections fully. The phrase "See C.V." is not acceptable as a response to any question. If additional space is needed for any of the questions or if the provider operates in more than four locations, extra sheets should be attached with appropriate references to the questions being answered.
A list of required documents is provided on page 10 of the application. Generally, these documents may include, but are not limited to, copies of current state medical licenses, board certifications, proof of professional liability insurance, and a recent Curriculum Vitae (C.V.). Carefully review the list on page 10 to ensure all necessary documents are included with your application.
While the application requests a Social Security Number (SSN), it’s important to comply with the form's instructions accurately. Many credentialing processes do require SSN for identity verification purposes. If there are any specific concerns about privacy or data protection, it's advisable to contact the entity requesting the application directly for clarification.
Yes, the application allows providers to list up to four practice locations directly on the form. If the provider practices at more than four locations, additional sheets should be attached, clearly referencing the question being answered, to provide complete information for additional practice locations.
Providers must list their primary and, if applicable, secondary and third specialties, including board certification details. A copy of the current certification(s) must be attached. It is also necessary to indicate whether the specialty and/or sub-specialty(ies) are practiced at each listed location and if they should be noted in any directories.
If additional space is needed for answers or if there are more than four practice locations, attach additional sheets to the application. Ensure that each attachment is clearly referenced back to the specific question or section it pertains to.
For questions regarding the application process or specific requirements, it's best to contact the organization requesting the credentialing application directly. They can provide guidance tailored to their specific credentialing requirements and procedures.
Completing the Louisiana Credentialing Application form is a crucial step in gaining access to various healthcare networks and can impact a healthcare provider's ability to practice within the state. However, errors in filling out this application can lead to delays or even denials of credentialing. Here are four common mistakes that healthcare providers make when completing the form:
Not providing complete information in all sections: The Louisiana Credentialing Application emphasizes that all sections must be filled out entirely. Leaving sections incomplete, or writing "See C.V." (curriculum vitae), is not acceptable and can lead to the rejection of the application. It's essential to provide detailed responses to every question, even if it means attaching additional sheets for more space, to ensure a smooth credentialing process.
Failure to match the Employer Identification Number (EIN) with IRS records: The application requires the practice location's Employer Identification Number (EIN) to match exactly with the records held by the IRS. Any discrepancy in this information can trigger verification problems and delay the application process. Double-checking the EIN against IRS documentation is crucial to avoid any issues.
Omitting required documents: On page 10 of the application, a list of required documents is provided, which must accompany the application. Failing to attach these critical documents, such as current certifications from the American Board of Medical Specialties or other recognized national certification bodies, can lead to an incomplete application process, necessitating additional time to request and review these documents.
Inaccurately listing practice locations or services provided: The application asks for detailed information about practice locations, including addresses, types of practice, and services offered. Misrepresenting or inaccurately listing this information can complicate the credentialing process. Specifically, providers must ensure accurate representation of their accessibility for disabled patients and compliance with the Americans with Disabilities Act (ADA), as this affects patient access and care quality.
Avoiding these mistakes is crucial in ensuring the credentialing process proceeds as smoothly and efficiently as possible. Taking the time to carefully review and accurately complete the Louisiana Credentialing Application form can significantly impact a healthcare provider's operational readiness and ability to serve patients within the state.
Completing the Louisiana Standardized Credentialing Application is a crucial step for healthcare providers in Louisiana. This application process often requires the inclusion of several other documents to provide a comprehensive profile of the provider's qualifications, practice settings, and legal compliance. Understanding these additional documents is essential for a smooth credentialing process.
For healthcare providers in Louisiana, successfully completing the credentialing process is pivotal in establishing trust and ensuring compliance with regulatory standards. The accompanying documentation plays a pivotal role in this process, highlighting the need for thorough preparation and attention to detail. Providers are encouraged to carefully gather and review these documents to facilitate a smooth and efficient credentialing experience.
The Louisiana Credentialing Application form is similar to various other documents healthcare providers are often required to complete. Highlighting its resemblances with other forms helps in understanding its comprehensive nature and the kind of information it gathers.
Firstly, it shares similarities with the Universal Provider Datasource (UPD) form that's widely used across the United States. Both forms require detailed personal information, professional qualifications, practice locations, and affiliations. Essentially, they collect data on education, work history, special certifications, and any other similar practice details. The key similarity lies in their objective: streamlining the credentialing process for healthcare providers by gathering all necessary data in a standardized format. This includes basic identification details, such as name and contact information, and extends to intricate professional affiliations and certifications. Both aim to make the credentialing process efficient by providing a comprehensive database for healthcare organizations.
Another document the Louisiana Credentialing Application resembles is the Medicare Enrollment Application (CMS-855). The CMS-855 form is specifically for healthcare providers seeking to enroll in the Medicare program, yet it parallels the Louisiana form in terms of the depth and breadth of information collected. Each requires the provider's personal demographic details, educational background, licensure information, and practice specifics. The congruence between these forms underscores their mutual aim of ensuring that healthcare providers meet certain standards and qualifications before being recognized by a larger entity, be it a state healthcare network or the federal Medicare program.
Moreover, its correlation with the Health Insurance Portability and Accountability Act (HIPAA) Business Associate Agreement (BAA) is more about regulatory compliance, yet still relevant. While the Louisiana Credentialing Application focuses more on provider information, the HIPAA BAA delves into the use and disclosure of protected health information (PHI). Although the HIPAA BAA is more specific to PHI protection, both documents underscore the importance of adhering to strict guidelines and standards within the healthcare industry. The Louisiana application ensures that a provider's credentials are vetted, while the HIPAA BAA ensures that PHI is handled in compliance with federal law. Together, they contribute to the overall integrity and confidentiality of healthcare services and information.
When filling out the Louisiana Credentialing Application form, there are critical steps to ensure the process is completed correctly and accurately. Below are things you should and should not do to enhance the success of your application process.
When it comes to filling out the Louisiana Credentialing Application form, several misconceptions can create roadblocks. Understanding these misconceptions is crucial for a smooth application process. Here are six common misunderstandings and clear explanations to help clarify them:
Correcting these misconceptions aids in completing the Louisiana Credentialing Application accurately and efficiently, ensuring that all required information is provided for credentialing purposes.
Filling out the Louisiana Credentialing Application form might seem like a daunting task, but it's an essential step for healthcare providers operating in Louisiana. This form is crucial for validating a provider's qualifications, ensuring they meet the state's standards for healthcare services. Here are some key takeaways to keep in mind when completing this application:
Accurately completing the Louisiana Credentialing Application form is a critical step for healthcare providers. It ensures patients have access to qualified and validated healthcare professionals, fostering trust within the healthcare system in Louisiana. By paying close attention to the details and requirements specified in the form, providers can navigate the credentialing process smoothly.
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