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Homepage ➼ Free Louisiana Credentialing Application Template
Structure

Navigating the complexities of credentialing within the healthcare sector in Louisiana necessitates a thorough understanding of the Louisiana Standardized Credentialing Application. This detailed form serves as a critical tool for healthcare professionals seeking to practice in various capacities across the state. It encompasses a wide spectrum of information, including personal details, educational background, certifications, practice locations, and affiliations with professional health organizations. The instructions clearly mandate the use of black ink for legibility and the importance of completeness—submissions directing to a Curriculum Vitae instead of providing direct answers are deemed unacceptable. Every section is vital, capturing data ranging from basic contact information to intricate details about office accessibility, signaling a commitment to inclusivity and accessibility standards like those outlined in the Americans with Disabilities Act (ADA). It’s also structured to gather nuanced information about practice types, languages offered, patient demographics, and emergency arrangements, painting a comprehensive picture of a practitioner's capabilities and the services offered at various locations. Additionally, it addresses affiliations with Physician Hospital Organizations (PHO) or Independent Practice Associations (IPA), which might reveal potential contractual conflicts, showcasing the form’s role not only in credentialing but also in maintaining ethical practice standards within the healthcare system.

Form 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

Free Louisiana Credentialing Application PDF

Document Breakdown

Fact Detail
Form Purpose The Louisiana Standardized Credentialing Application is designed for healthcare professionals to provide their qualifications and practice details comprehensively for credentialing with healthcare organizations.
Fill-out Instructions Applicants must type or print in black ink, complete all sections entirely without referring to a CV, and attach additional sheets if more space is needed or if they have more than four practice locations.
Document Requirements A list of required documents is provided on page 10 of the form, which must be submitted alongside the completed application to ensure thorough evaluation.
Accessibility and Language The form inquires about the types of access provided at practice locations (e.g., wheelchair access), languages spoken other than English, and compliance with the Americans with Disabilities Act (ADA).
Patient and Practice Information Details including types of patients accepted, age groups treated, practice type, and office hours for up to four practice locations are requested to understand the applicant's practice scope and availability.
Governing Law While the form serves a vital function in credentialing within Louisiana, it adheres to state-specific regulations governing healthcare practitioners, as well as federal laws like the ADA, ensuring practices are accessible and non-discriminatory.

Instructions on Filling in Louisiana Credentialing Application

Filling out the Louisiana Credentialing Application form is a vital step for healthcare providers in Louisiana aiming to be recognized and to affiliate with different healthcare plans. This detailed form requires careful attention to ensure all information provided is accurate and complete. Below are the steps designed to assist you in completing the form with ease.

  1. Starting with the GENERAL INFORMATION section, provide your last name, first name, middle name, and any suffixes. If applicable, include any other names you've been known by.
  2. Mark the appropriate box for your gender and enter your degree type. If your degree is not listed, specify under "Other".
  3. Fill in your ECFMG Number and UPIN Number if applicable.
  4. Provide your home address, including the street, city, state, and zip code. Also, include your home phone number, pager number or answering service, and a home email address if you opt to.
  5. Enter your Social Security Number, date of birth, place of birth (city, state), and, optionally, your race/ethnicity.
  6. Supply your NPI - Individual, Medicaid Provider Number, and Medicare Provider Number in the designated spaces.
  7. Move on to the PRIMARY PRACTICE LOCATION section. Fill in the details about your primary practice, including the institution/group/clinic name, office manager, and tax identification number.
  8. Detail the practice location’s addresses – physical, billing, correspondence, and medical records, including phone numbers, emails, and fax numbers for each.
  9. Specify the type of practice, owner name if applicable, office hours, and the practice's accessibility details, such as handicap accessibility and services offered for the disabled. Mark the boxes corresponding to your answers.
  10. Indicate whether you’re accepting new patients, the age group(s) you treat, and other operational specifics of the practice.
  11. Use the same approach to provide details for your SECOND, THIRD, and FOURTH PRACTICE LOCATION if you have more than one. Remember to attach additional sheets if you have more than four practice locations, ensuring you reference the corresponding question.
  12. In the SPECIALTY & CERTIFICATION section, attach a copy of your current certification(s) as required. Define your provider type, list your specialties and board certifications accurately.
  13. For the DIRECTORY INFORMATION section, check the appropriate boxes to indicate which specialties and/or subspecialties are practiced at each location and whether these should be noted in the directory.
  14. In the PHO / IPA AFFILIATIONS section, list any PHO's or IPA's you participate in, including the dates of participation.
  15. Finally, review the entire form to ensure all information is correct and complete. Attach the list of required documents as mentioned on page 10 of the form.

Once you have completed the form and attached all necessary documents, you are ready to submit it to the designated entity as indicated in the application instructions. Taking the time to fill out this application thoroughly will help streamline the credentialing process, allowing you to focus on providing care to your patients.

Listed Questions and Answers

What is the purpose of the Louisiana Standardized Credentialing Application?

The Louisiana Standardized Credentialing Application is designed to streamline the credentialing process for healthcare providers wishing to practice in the state of Louisiana. By completing this form, healthcare providers supply necessary information to healthcare organizations, insurance companies, and regulatory bodies, ensuring they meet the standards required to provide medical services in the state.

How should the application form be completed?

The form should be completed by typing or printing in black ink. All sections of the application must be filled out completely. If additional space is required or if the provider operates at more than four locations, additional sheets should be attached with referenced questions clearly indicated. Phrases like "See C.V." are not acceptable as responses.

What documents are required to be submitted with the application?

A list of required documents is provided on page 10 of the application. Generally, these documents include, but may not be limited to, copies of current certifications, proof of education, licenses to practice, and any other documents that verify the qualifications and credentials of the healthcare provider.

Who must fill out the Louisiana Standardized Credentialing Application?

This application must be filled out by any healthcare provider who seeks to establish or continue their medical practice within the state of Louisiana. This includes, but is not limited to, physicians (MD, DO), dentists (DDS, DMD), chiropractors (DC), and podiatrists (DPM), among others.

Is it necessary to fill out multiple forms if I practice at more than one location?

No, it is not necessary to fill out multiple forms if you practice at more than one location. The application provides sections to list up to four practice locations. If you have more than four locations, you should attach additional sheets with the required information for each additional location.

Can information be provided in a format other than the spaces provided on the application form?

Yes, if more space is needed or specific questions require detailed answers beyond the space provided, additional sheets can be attached to the application. It is important to reference the question number being answered on these additional sheets to ensure clarity.

What should I do if my practice offers services in languages other than English?

For practices offering services in languages other than English, the languages spoken should be clearly listed in the section provided. This information helps in ensuring that patients who do not speak English can receive care in a language they are comfortable with.

How do I handle sections that are not applicable to my practice?

For sections that are not applicable to your practice, it is recommended to mark them as "N/A" to indicate that they do not apply. This demonstrates that you have reviewed every section of the application without leaving any parts unintentionally blank.

Common mistakes

Filling out the Louisiana Credentialing Application form can be a daunting task, but it's crucial to your professional journey. There are common pitfalls that many people encounter during this process. To ensure accuracy and completeness, let's take a look at seven key mistakes:

  1. Not using black ink or typing when completing the form. This helps ensure that the application is legible and professionally presented, reducing the likelihood of errors or misinterpretation of information.
  2. Omitting additional sheets when more space is needed. For those who have more than four locations or need extra space to provide thorough answers, forgetting to attach additional sheets can lead to incomplete responses, which might affect the application's evaluation.
  3. Leaving sections incomplete or directing reviewers to the CV instead of filling out all sections entirely. The instructions clearly state that all sections must be completed in their entirety, and responses such as "See C.V." are not acceptable.
  4. Not attaching a list of required documents as indicated on page 10. This oversight can lead to delays in processing the application or even its outright rejection.
  5. Failing to provide accurate and matching information for employer identification numbers and IRS registration. This could lead to administrative issues or discrepancies that might complicate credential confirmation.
  6. Overlooking the specifics of the practice location sections, such as accessibility features, languages spoken, and emergency after-hours contact information. This information is vital for a comprehensive understanding of your practice's capabilities and environment.
  7. Incorrectly listing or failing to list specialty and certification information, including board certifications. This error can misrepresent your qualifications to the board and potential patients.

Avoiding these mistakes can significantly impact the success of your Louisiana Credentialing Application. Approach the task with attention to detail and a thorough understanding of the requirements to facilitate a smoother credentialing process.

Documents used along the form

When submitting the Louisiana Standardized Credentialing Application, various additional forms and documents are frequently required to ensure a comprehensive review and processing of the application. These documents play a crucial role in establishing the credentials and qualifications of healthcare providers, facilitating their partnership with hospitals, clinics, and insurance providers.

  • Curriculum Vitae (CV): A detailed account of the applicant’s education, work experience, certifications, and other professional achievements that provide background and context beyond the application form.
  • Copy of Medical License: An official document issued by the state’s medical board verifying the applicant’s legal authorization to practice medicine within the state of Louisiana.
  • Board Certification Documents: Certificates indicating the applicant’s specialization(s) recognized by the American Board of Medical Specialties or other national certification bodies, underscoring expertise in specific areas of medicine.
  • Proof of Professional Liability Insurance: Evidence of current malpractice or professional liability insurance coverage, showcasing financial protection against claims of negligence or misconduct.
  • Drug Enforcement Administration (DEA) Certificate: A document authorizing the applicant to prescribe controlled substances as part of their medical practice, highlighting adherence to regulatory standards.
  • Continuing Medical Education (CME) Certificates: Documentation of completed CME credits, demonstrating ongoing education and commitment to staying updated in the medical field.
  • Letters of Recommendation: Written endorsements from colleagues or supervisors that attest to the applicant’s skills, character, and competence, providing insight into their professional reputation.
  • Malpractice Claims History: A record of any past malpractice claims or legal actions taken against the applicant, offering transparency and understanding of their professional conduct and patient care standards.

Together, these forms and documents complement the Louisiana Credentialing Application by providing a thorough profile of the applicant’s qualifications and history. Careful compilation and submission of these materials help facilitate smoother verification processes, promoting efficient and effective healthcare collaborations.

Similar forms

The Louisiana Credentialing Application form is similar to the American Medical Association (AMA) Physician Profile and the National Provider Identifier (NPI) application. The similarities among these documents lie mainly in the type of detailed professional information they collect, which includes but is not limited to, general personal information, educational background, and practice details. All three require comprehensive personal and professional details to ensure accurate representation of a provider's current and past status. Additionally, they all adhere to stringent guidelines for completeness and accuracy.

Like the Louisiana Credentialing Application, the AMA Physician Profile is extensive and is designed to provide a complete view of a doctor's professional credentials. This includes education, training, specialty certifications, and a detailed work history. Both documents serve as a thorough record for verification purposes, aiding institutions such as hospitals, insurance companies, and state medical boards in confirming a physician's qualifications. The major difference lies in the audience; while the credentialing application is specific to Louisiana, the AMA profile has a broader reach, catering to nationwide verification needs.

Similarly, the National Provider Identifier (NPI) application shares common ground with the Louisiana Credentialing Application, particularly in the requirement for detailed practice location information, including practice names, addresses, and contact details. Both forms are indispensable in the healthcare industry for billing and identification purposes. The NPI application, like the credentialing form, necessitates the disclosure of primary and secondary practice locations and the nature of the practice. The NPI is a unique identification number for covered health care providers in the United States, thereby serving as a critical tool for ensuring that medical billing and records are properly attributed.

Dos and Don'ts

Completing the Louisiana Credentialing Application form is a critical step in the credentialing process. Ensuring the accuracy and completeness of this form is not only a reflection of your professionalism but also crucial for a successful credentialing process. Below are essential dos and don'ts to consider when filling out this form:

  • Do type or print in black ink to ensure that all information is legible.
  • Do attach additional sheets if you have more than four practice locations or if the given space is insufficient, ensuring to reference the question being answered clearly.
  • Do complete all sections in their entirety. Responding with “See C.V.” is not acceptable and can delay the credentialing process.
  • Do include a current copy of your specialty and certification documents as recognized by the American Board of Medical Specialties or other national certification body.
  • Do carefully review the list of required documents on page 10 of the application to ensure nothing is missed.
  • Do provide any other names under which you have been known, to avoid any discrepancies or delays in the credentialing process.
  • Don't leave any sections incomplete. Any missing information can significantly delay the credentialing process.
  • Don't assume that the reviewing party knows any of the specifics about your practice or background. Provide complete details wherever required.
  • Don't forget to sign and date the application. An unsigned application is considered incomplete.
  • Don't use correction fluid or make alterations on the form. If a mistake is made, it’s better to start with a fresh form to maintain the professional appearance of your application.
  • Don't overlook the requirement to match the Employer Identification Number (EIN) with the IRS records exactly. This is crucial for the verification process.
  • Don't forget to check the box indicating whether your office meets the Americans with Disabilities Act (ADA) requirements, as it is important for patient accessibility.

Adhering to these guidelines will help ensure your Louisiana Credentialing Application is accurately and thoroughly completed, facilitating a smoother credentialing process.

Misconceptions

The Louisiana Standardized Credentialing Application is a critical document for healthcare providers in the state, ensuring that their qualifications, practice locations, and certifications are accurately recorded and easily accessible for credentialing purposes. However, there are several misconceptions surrounding this application that need to be addressed for a smoother credentialing process.

  • All sections must be answered thoroughly without referring to an attached CV: Many applicants mistakenly believe that indicating "See C.V." for any section is sufficient. However, the application requires each section to be completed in detail to ensure comprehensive credentialing.

  • Black ink is not a suggestion: The instruction to print or type in black ink is often overlooked or treated as a suggestion. Using black ink ensures the document is legible and can be scanned or photocopied without loss of clarity, which is essential for processing the application accurately.

  • Additional sheets are acceptable: There’s a common misconception that all information must fit within the provided space of the application form. If more space is needed, attaching additional sheets with clear references to the corresponding question is not only allowed but encouraged for clarity.

  • Every practice location requires separate details: Some applicants consolidate information about multiple practice locations. Each location where a provider practices must have its information provided separately to ensure location-specific details, such as accessibility and specialist services available, are accurately captured.

  • Accessibility details are crucial: Information regarding the accessibility of practice locations is often underrated. These details are critical for patients with disabilities and for compliance with the Americans with Disabilities Act (ADA), ensuring that all patients have equal access to healthcare services.

  • Specialty and certification must be backed by documentation: It's wrongly assumed that listing boards of certification is enough. Actual documentation and proof of current certification(s) must be attached to the application to verify the provider's specialties and qualifications.

  • PA/Nurse/Paraprofessional usage needs clarification: There is a misunderstanding about specifying the use of Physician Assistants (PAs) or nurse/paraprofessionals. Clarifying this usage helps patients understand the type of care and support staff available at each location.

  • Emergency after-hours coverage is mandatory: Neglecting to detail arrangements for emergency after-hours coverage is a common oversight. The application requires specifying how 24/7 coverage is managed, whether through a group, covering, or collaborating physicians, ensuring patients have continuous access to care.

  • Directory information impacts patient referral: Often overlooked, the section on how specialty or subspecialties are to be listed in directories affects referrals. Accurately indicating this information ensures that patients and referring providers know the services offered at each practice location.

  • PHO/IPA affiliations require up-to-date listings: Failing to provide current information on Preferred Hospital Organizations (PHOs) or Independent Practice Associations (IPAs) with which a provider participates can lead to conflicts regarding plan participation. This section identifies contractual arrangements crucial for credentialing and referral processes.

By addressing these misconceptions, healthcare providers can ensure that the credentialing process is expedited and that their practice information is accurately represented, ultimately benefiting the provider, the patients, and the healthcare system at large.

Key takeaways

Filling out the Louisiana Credentialing Application form is an essential step for healthcare providers in Louisiana looking to affiliate with various health plans, hospitals, and other healthcare organizations. It helps streamline the credentialing process, ensuring providers meet the necessary standards to offer healthcare services. To navigate this process smoothly, here are six key takeaways to consider:

  • Ensure all sections of the application are completed in full. Using shortcuts such as referencing a Curriculum Vitae (CV) instead of filling out the form details is not allowed. This requirement underscores the importance of providing comprehensive and accurate information directly within the form.
  • For sections requiring information on practice locations, accurately detail up to four locations where services are provided. If more than four locations exist, additional sheets must be attached, indicating all relevant location information consistently across each entry.
  • Alongside general and practice location information, the form emphasizes compliance with the Americans with Disabilities Act (ADA). Providers must disclose the accessibility of their facilities, including details on handicapped access for buildings, parking, restrooms, and availability of services like text telephony (TTY) and American Sign Language.
  • The application requires specifics regarding the age groups treated and whether the provider's office accepts new patients, only family members of existing patients, or existing patients only. This information is crucial for ensuring that patient populations are adequately served and matched with the provider’s specialties and capabilities.
  • Special attention must be given to the documentation of board certifications and specialty recognitions as defined by the American Board of Medical Specialties or other national certification bodies. Attaching copies of current certification(s) is mandatory, reinforcing the provider's qualifications and areas of expertise.
  • Lastly, the application inquires about any affiliations with Physician Hospital Organizations (PHOs) or Independent Practice Associations (IPAs) to identify any potential contractual conflicts with the plans. Complete and transparent reporting of such affiliations is required for a thorough credentialing review.

Completing the Louisiana Credentialing Application form with attention to detail not only facilitates a smoother credentialing process but also ensures compliance with statewide standards for practice. It’s a critical step in establishing a trustworthy and professional healthcare practice in Louisiana.

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