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Blank Louisiana Credentialing Application PDF Form

The Louisiana Credentialing Application form is a standardized document used by healthcare providers to obtain necessary credentials for practice in the state. This comprehensive application requires detailed information about the provider's personal background, practice locations, and specialties. Completing this form accurately is essential, as it ensures compliance with state regulations and facilitates the credentialing process.

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Blank Louisiana Credentialing Application PDF Form

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The Louisiana Credentialing Application form is a critical document for healthcare providers seeking to establish their practice within the state. This form requires comprehensive information, ensuring that all necessary details are accurately captured to facilitate the credentialing process. Applicants must provide personal information such as their full name, gender, and contact details, along with professional qualifications including degrees and certifications. Additionally, the form mandates disclosure of practice locations, encompassing details like the institution's name, physical address, office hours, and the types of services offered. Special attention is given to accessibility features and patient demographics, reflecting a commitment to inclusivity in healthcare services. Each section of the application must be completed in full, as incomplete submissions can lead to delays or rejections. Notably, the form emphasizes the importance of providing accurate tax identification numbers and National Provider Identifiers (NPIs), which are essential for billing and insurance purposes. Overall, this application serves as a foundational step for providers aiming to deliver care in Louisiana, aligning their practices with state regulations and standards.

Document 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-employed  Healthplan/Payor-owned

If Hospital-employed or Healthplan/Payor-owned, please indicate owner name:__________________________________________

Office Hours	Mon.		Tues.		Wed.	Thur.	Fri.	Sat.	Sun.
Office Hours	_____-_____		_____-_____	_____-_____		_____-_____	_____-_____	_____-_____	_____-_____
	_____-_____		_____-_____	_____-_____		_____-_____	_____-_____	_____-_____	_____-_____
Do you practice at this location:		 Full-time		 Part-time		 Other (Specify) _______________________________

Languages spoken at this location (other than English):					____________________		____________________		Provider
Languages spoken at this location (other than English):					____________________		____________________		Other
									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-employed  Healthplan/Payor-owned

If Hospital-employed or Healthplan/Payor-owned, please indicate owner name:__________________________________________

Office Hours	Mon.		Tues.		Wed.	Thur.	Fri.	Sat.	Sun.
Office Hours	_____-_____		_____-_____	_____-_____		_____-_____	_____-_____	_____-_____	_____-_____
	_____-_____		_____-_____	_____-_____		_____-_____	_____-_____	_____-_____	_____-_____
Do you practice at this location:		 Full-time		 Part-time		 Other (Specify) _______________________________

Languages spoken at this location (other than English):					____________________		____________________		Provider
Languages spoken at this location (other than English):					____________________		____________________		Other
									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
Age group(s) treated:	 Over 65	 All Ages	 Other (Specify): ______________________________

Are PAs and/or nurse/paraprofessional	Yes No		Is this facility wheelchair/ handicapped				Yes No
practitioners used?	Yes No		accessible?				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
		Type of Residency			 Research
					 Research
City		State			Dates Attended (MO/YR):
					From: _______ to _______

University Affiliation		Completed:	 Yes	 No
		Completed:	 Yes	 No

Residency: Institution Name		Type of Residency			 Clinical
		Type of Residency			 Research
					 Research
City		State			Dates Attended (MO/YR):
					From: _______ to _______

University Affiliation		Completed:	 Yes	 No
		Completed:	 Yes	 No

Fellowship: Institution Name		Specialty Field			Dates Attended (MO/YR):
					From: _______ to _______

City		State			Completed
					 Yes	 No
		Type of Fellowship			 Clinical
		Type of Fellowship			 Research
					 Research

Fellowship: Institution Name		Subspecialty Fields			Dates Attended (MO/YR):
					From: _______ to _______

City		State			Completed
					 Yes	 No

		Type of Fellowship			 Clinical
		Type of Fellowship			 Research
					 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		/
				/	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)	 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.


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

Dos and Don'ts

Do complete all sections of the application in their entirety. Leaving any section blank can lead to delays or rejection.
Do use black ink or type the information clearly. This ensures that your application is legible and easy to process.
Do attach additional sheets if you need more space for your answers. Be sure to reference the specific question you are answering.
Do include your current certification documents as required. This is essential for verifying your qualifications.
Don't write "See C.V." in any section. Each part of the application must be filled out fully.
Don't provide outdated or incorrect information. Ensure that all details match those on your official documents, particularly your Tax Identification Number and NPI.

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Detailed Instructions for Filling Out Louisiana Credentialing Application

Completing the Louisiana Credentialing Application form requires careful attention to detail. Ensure that you have all necessary information and documents at hand before starting. Once you have filled out the form, you will be able to submit it for processing.

Begin with the General Information section. Fill in your last name, suffix, first name, middle name, and gender.
Indicate your degree and any other names you have been known by.
Provide your ECFMG number, UPIN number, home address, phone numbers, email address (optional), Social Security number, date of birth, birthplace, race/ethnicity (optional), NPI, Medicaid provider number, and Medicare provider number.
Move to the Primary Practice Location section. Enter the institution/group/clinic name, office manager, tax identification number, and effective date of provider at this location.
Fill in the NPI for the group, physical address, office email, website, main phone number, appointment phone number, and fax number.
Complete the billing address, contact person details, correspondence address, and medical records address sections.
Specify the type of practice and office hours. Indicate if you practice full-time, part-time, or other, and list any languages spoken.
Answer questions regarding patient acceptance, age groups treated, and accessibility features of the facility.
If applicable, repeat the above steps for the Second, Third, and Fourth Practice Locations.
In the Specialty & Certification section, list your specialties and attach copies of your current certifications.
Check the directory information for each location, indicating specialties and whether they should be noted in the directory.
Finally, list any PHO or IPA affiliations, including dates of participation.

Documents used along the form

The Louisiana Credentialing Application form is a critical document for healthcare providers seeking to establish their credentials. Along with this form, several other documents are often required to complete the application process. Below is a list of commonly used forms and documents that may accompany the Louisiana Credentialing Application.

Curriculum Vitae (C.V.) - A detailed document outlining the provider's educational background, work experience, and professional accomplishments.
Proof of Medical Licensure - Documentation verifying that the provider holds a valid medical license in the state of Louisiana.
Board Certification Documentation - Certificates or letters indicating the provider's board certifications in their respective specialties.
Malpractice Insurance Information - Evidence of current malpractice insurance coverage, including policy details and effective dates.
National Provider Identifier (NPI) Verification - A document confirming the provider's NPI number, which is essential for billing and identification purposes.
Background Check Results - Documentation of any required background checks, which may include criminal history and other relevant screenings.
References - Letters or forms from professional colleagues or supervisors attesting to the provider's qualifications and character.
Quitclaim Deed Form: For transferring property ownership, ensure you review our step-by-step Quitclaim Deed guide to complete the process effectively.
Continuing Education Certificates - Proof of completion of required continuing education courses relevant to the provider's specialty.
Application Fee Payment Receipt - A receipt or confirmation of payment for any fees associated with the credentialing process.

These documents collectively support the credentialing process, ensuring that healthcare providers meet the necessary qualifications and standards. It is important to carefully review the specific requirements for each application to ensure all necessary documentation is included.

Your Questions, Answered

What is the purpose of the Louisiana Credentialing Application form?

The Louisiana Credentialing Application form is designed to collect essential information about healthcare providers. This application facilitates the credentialing process, allowing providers to be recognized by insurance companies and healthcare organizations. It ensures that all relevant details regarding a provider's qualifications, practice locations, and specialties are accurately documented. Completing this form is a necessary step for providers seeking to practice in Louisiana and to be eligible for reimbursement from various payers.

What information is required to complete the application?

Completing the Louisiana Credentialing Application requires detailed personal and professional information. Key sections include:

General Information: This includes the provider's name, gender, degrees, and contact details.
Primary Practice Location: Providers must provide information about their main practice, including the institution name, physical address, and office hours.
Specialty & Certification: Information about the provider's specialties and any board certifications must be included.
Directory Information: Providers are asked to indicate which specialties should be listed in directories.

It is crucial to complete all sections fully, as incomplete forms may delay the credentialing process.

Can additional sheets be attached if there are more than four practice locations?

Yes, if a provider has more than four practice locations, additional sheets can be attached to the application. Each additional sheet should reference the specific question being answered to maintain clarity. This allows for a comprehensive representation of all practice sites without compromising the organization of the application.

What happens if the application is incomplete or contains errors?

Submitting an incomplete application or one with errors can lead to significant delays in the credentialing process. Credentialing committees may return the application for corrections or additional information, which can prolong the time it takes for a provider to become credentialed. Therefore, it is essential to review the application thoroughly before submission to ensure all required fields are completed accurately.

Are there any specific documents that need to be submitted with the application?

Yes, along with the Louisiana Credentialing Application, providers must attach specific documents as outlined on page 10 of the form. These documents typically include copies of licenses, certifications, and any other relevant credentials that verify the provider's qualifications. Ensuring that these documents are current and accurately reflect the provider's credentials is critical for a successful application process.

Common mistakes

Filling out the Louisiana Credentialing Application can be a straightforward process, but many applicants make common mistakes that can lead to delays or complications. One significant error is failing to complete all sections of the application. The instructions clearly state that **all sections must be completed in their entirety**. Simply writing "See C.V." is not acceptable. This oversight can result in the application being returned or rejected, causing unnecessary delays.

Another frequent mistake involves providing incorrect or inconsistent information. For example, the application requires that the Tax Identification Number (TIN) and the Employer Identification Number (EIN) match exactly with IRS records. If discrepancies arise, it can create confusion and hinder the credentialing process. Ensuring that all numbers and names are accurate is crucial for a smooth application.

Many applicants also overlook the importance of including required documents. The application specifies a list of documents needed, and failing to attach these can lead to immediate rejection. It's advisable to review the list on page 10 carefully and ensure that everything is included before submission.

Another common issue is neglecting to specify practice locations correctly. Applicants sometimes forget to indicate whether they practice full-time or part-time at each location. This detail is essential for credentialing organizations to understand the applicant's availability and scope of practice. Providing clear and accurate information about practice hours and locations helps avoid misunderstandings.

Lastly, applicants often underestimate the significance of the contact information provided. Missing or incorrect phone numbers and email addresses can impede communication between the credentialing body and the applicant. It is vital to double-check that all contact details are correct and up-to-date to ensure timely correspondence.

Misconceptions

Misconceptions about the Louisiana Credentialing Application form can lead to confusion and mistakes during the application process. Here are six common misconceptions, along with clarifications for each.

All sections can be left blank if not applicable. Many applicants believe they can skip sections that do not apply to them. However, the form requires that all sections be completed in their entirety. Leaving sections blank may result in delays or rejection of the application.
Using "See C.V." is an acceptable response. Some applicants think they can reference their curriculum vitae instead of providing detailed information on the form. This is incorrect. The instructions clearly state that using "See C.V." is not acceptable, and all information must be included directly on the application.
Only physicians need to complete this form. A misconception exists that this application is solely for physicians. In reality, various healthcare providers, including specialists and allied health professionals, must also complete this application to be credentialed.
Additional sheets are not necessary for extra locations. Some applicants assume they can only list one practice location. If you have more than four locations, you must attach additional sheets. The form explicitly states to reference the question being answered when providing this information.
Providing a Social Security Number is optional. Many applicants mistakenly believe that including their Social Security Number is optional. In fact, this information is required for the credentialing process and should be provided unless there are specific legal reasons for withholding it.
Language proficiency is not important. Some individuals think that listing languages spoken at the practice location is irrelevant. However, this information is crucial for patient communication and is a requirement on the form. It enhances the practice’s ability to serve diverse populations.

Document Attributes

Fact Name	Details
Form Purpose	This application is used for credentialing healthcare providers in Louisiana.
Completion Requirement	All sections of the form must be completed fully. Partial answers are not acceptable.
Document Submission	Required documents must be attached as specified on page 10 of the application.
Personal Information	Applicants must provide personal details including name, gender, and Social Security Number.
Practice Locations	Information for up to four practice locations can be provided. Additional sheets may be attached if needed.
ADA Compliance	Applicants must indicate if their facility meets the Americans with Disabilities Act (ADA) requirements.
Emergency Coverage	Details for after-hours emergency coverage must be provided on the form.
Specialty Certification	Applicants should attach copies of current specialty certifications recognized by the appropriate boards.
Language Requirements	Applicants can list languages spoken at their practice locations, other than English.
Governing Laws	The application is governed by Louisiana state laws regarding healthcare provider credentialing.