Get Louisiana Standardized Credentialing Application 2012-2024

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 9 for a list of required documents. 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 NAME AND ADDRESS OF ENTITY DATE From MO/YR to MO/YR In the following section please explain any gaps of two months or more in your education post-graduate training or work history PROFESSIONAL LICENSES LICENSE NUMBER DATE OBTAINED EXPIRATION DATE STATE LICENSE FEDERAL DEA REG 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 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 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 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 NAME OF CARRIER POLICY NUMBER ADDRESS AND PHONE NUMBER OF CARRIER AMOUNTS PER OCCURRENCE/AGGREGATE DATES OF COVERAGE Do you participate in the Louisiana Patients Compensation Fund Has current liability insurance carrier required exclusion of any procedures from insurance coverage If yes attach explanation Are you self-insured in accordance with the Louisiana Medical Malpractice Act 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. All sections must be completed in their entirety. See C. V. not acceptable GENERAL INFORMATION LAST NAME DEGREE SUFFIX MD DO FIRST DPM MIDDLE DC DDS GENDER MALE FEMALE DMD OTHER Any other name under which you have been known AKA LIST ECFMG NUMBER UPIN NUMBER HOME STREET ADDRESS CITY STATE HOME PHONE NUMBER PAGER NUMBER/ANSWERING SERVICE SOCIAL SECURITY NUMBER DATE OF BIRTH NPI - INDIVIDUAL HOME E-MAIL ADDRESS Optional BIRTH PLACE CITY STATE NPI GROUP ZIP CODE RACE/ETHNICITY Voluntary MEDICAID PROVIDER NUMBER PRIMARY PRACTICE LOCATION INSTITUTION/GROUP/CLINIC NAME If applicable OFFICE MANAGER STREET ADDRESS FAX NUMBER TYPE OF PRACTICE SOLO OFFICE E-MAIL MULTISPECIALTY GROUP TAX IDENTIFICATION NUMBER/ DATE TAX ID EFFECTIVE - PROVIDER SINGLE SPECIALTY GROUP HOSPITAL-BASED Name to which Employer Identification Number EIN is registered with the IRS Important must match IRS information exactly BILLING ADDRESS Address to which you want payments sent CONTACT PERSON TELEPHONE NUMBER BILLING E-MAIL OFFICE HOURS MON - Do you practice at this location TUES Full-time WED THUR Part-time Languages spoken at this location other than English FRI SAT SUN Other Specify Provider Other Accepting Patients New Existing Only Only family members of existing patients Age group s treated 0-6 years Over 65 7-11 years All Ages Are PAs and/or nurse/paraprofessional practitioners used Emergency After Hours Number Group or Covering Physicians Revised February 2008 12-18 years 19-65 years Yes No Is this facility handicapped accessible Arrangements for 24 hour / 7 day a week coverage Specify Page 1 of 9 SECOND PRACTICE LOCATION Name to which tax ID number is registered with the IRS Important must match the name given on IRS information given THIRD PRACTICE LOCATION FOURTH PRACTICE LOCATION If you have more than four locations attach additional sheets with the following information CORRESPONDENCE Please check location where you would like correspondence sent.