LOUISIANA STANDARDIZED CREDENTIALING APPLICATION
[Pages:9]LOUISIANA STANDARDIZED CREDENTIALING APPLICATION
DIRECTIONS
Please type or print in black ink when completing this form. If you need more space or have more than four locations, attach additional sheets and reference the question being answered. Please see page 9 for a list of required documents.
** All sections must be completed in their entirety. "See C.V.", not acceptable**
GENERAL INFORMATION
LAST NAME
SUFFIX FIRST
MIDDLE
GENDER T MALE T 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 E-MAIL ADDRESS (Optional)
SOCIAL SECURITY NUMBER
DATE OF BIRTH BIRTH PLACE (CITY, STATE) RACE/ETHNICITY (Voluntary)
NPI - INDIVIDUAL
NPI ? GROUP
MEDICAID PROVIDER NUMBER MEDICARE PROVIDER NUMBER
PRIMARY PRACTICE LOCATION
INSTITUTION/GROUP/CLINIC NAME (If applicable)
OFFICE MANAGER
STREET ADDRESS
CITY
STATE
PHONE NUMBER
FAX NUMBER
OFFICE E-MAIL
ZIP CODE
TYPE OF PRACTICE:
SOLO
MULTISPECIALTY GROUP
SINGLE SPECIALTY GROUP
HOSPITAL-BASED
TAX IDENTIFICATION NUMBER/ DATE TAX ID # EFFECTIVE - PROVIDER TAX IDENTIFICATION NUMBER/ DATE TAX ID # EFFECTIVE - LOCATION
Name to which Employer Identification Number (EIN) is registered with the IRS (Important: must match IRS information exactly)
BILLING ADDRESS (Address to which you want payments sent) CONTACT PERSON
TELEPHONE NUMBER
CITY
STATE
ZIP CODE
BILLING E-MAIL
FAX NUMBER
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 Existing Only
Only family members of existing patients Other (Specify) _________________________________________________
Age group(s) treated:
0-6 years Over 65
7-11 years All Ages
12-18 years
19-65 years
Other (Specify): ______________________________
Are PAs and/or nurse/paraprofessional practitioners used? Yes No Is this facility handicapped accessible? Yes No
Emergency After Hours Number
Arrangements for 24 hour / 7 day a week coverage (Specify)
Group or Covering Physicians:
Revised February 2008
_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
Page 1 of 9
SECOND PRACTICE LOCATION
INSTITUTION/GROUP/CLINIC NAME (If applicable)
OFFICE MANAGER
STREET ADDRESS
CITY
STATE
PHONE NUMBER
FAX NUMBER
OFFICE E-MAIL
ZIP CODE
TYPE OF PRACTICE:
SOLO
MULTISPECIALTY GROUP
SINGLE SPECIALTY GROUP
HOSPITAL-BASED
TAX IDENTIFICATION NUMBER/ DATE TAX ID # EFFECTIVE - PROVIDER TAX IDENTIFICATION NUMBER/ DATE TAX ID # EFFECTIVE - LOCATION
Name to which tax ID number is registered with the IRS (Important: must match the name given on IRS information given)
BILLING ADDRESS (Address to which you want payments sent) CONTACT PERSON
TELEPHONE NUMBER
CITY
STATE
ZIP CODE
BILLING E-MAIL
FAX NUMBER
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 Existing Only
Only family members of existing patients Other (Specify): _________________________________________________
Age group(s) treated:
0-6 years Over 65
7-11 years All Ages
12-18 years
19-65 years
Other (Specify): ______________________________
Are PAs and/or nurse/paraprofessional practitioners used? Yes No Is this facility handicapped Accessible? Yes No
Emergency After Hours Number
Arrangements for 24 hour / 7 day a week coverage (Specify)
_______________________________________________________________________________ Group or Covering Physicians: _______________________________________________________________________________
_______________________________________________________________________________
THIRD PRACTICE LOCATION
INSTITUTION/GROUP/CLINIC NAME (If applicable)
OFFICE MANAGER
STREET ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
FAX NUMBER
OFFICE E-MAIL
TYPE OF PRACTICE:
SOLO
MULTISPECIALTY GROUP
SINGLE SPECIALTY GROUP
HOSPITAL-BASED
TAX IDENTIFICATION NUMBER/ DATE TAX ID # EFFECTIVE - PROVIDER TAX IDENTIFICATION NUMBER/ DATE TAX ID # EFFECTIVE - LOCATION
Name to which tax ID number is registered with the IRS (Important: must match the name given on IRS information given)
BILLING ADDRESS (Address to which you want payments sent) CONTACT PERSON
TELEPHONE NUMBER
CITY
STATE
ZIP CODE
BILLING E-MAIL
FAX NUMBER
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 9
Accepting Patients? Age group(s) treated:
THIRD PRACTICE LOCATION CONTINUED
New Existing Only
Only family members of existing patients Other (Specify): _________________________________________________
0-6 years Over 65
7-11 years All Ages
12-18 years
19-65 years
Other (Specify): ______________________________
Are PAs and/or nurse/paraprofessional practitioners used? Yes No Is this facility handicapped Accessible? Yes No
Emergency After Hours Number
Arrangements for 24 hour / 7 day a week coverage (Specify)
_______________________________________________________________________________ Group or Covering Physicians: _______________________________________________________________________________
_______________________________________________________________________________
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
STREET ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
FAX NUMBER
OFFICE E-MAIL
TYPE OF PRACTICE:
SOLO
MULTISPECIALTY GROUP
SINGLE SPECIALTY GROUP
HOSPITAL-BASED
TAX IDENTIFICATION NUMBER/ DATE TAX ID # EFFECTIVE - PROVIDER TAX IDENTIFICATION NUMBER/ DATE TAX ID # EFFECTIVE - LOCATION
Name to which tax ID number is registered with the IRS (Important: must match the name given on IRS information given)
BILLING ADDRESS (Address to which you want payments sent) CONTACT PERSON
TELEPHONE NUMBER
CITY
STATE
ZIP CODE
BILLING E-MAIL
FAX NUMBER
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 Existing Only
Only family members of existing patients Other (Specify): _________________________________________________
Age group(s) treated:
0-6 years Over 65
7-11 years All Ages
12-18 years
19-65 years
Other (Specify): ______________________________
Are PAs and/or nurse/paraprofessional practitioners used? Yes No Is this facility handicapped Accessible? Yes No
Emergency After Hours Number
Arrangements for 24 hour / 7 day a week coverage (Specify)
_______________________________________________________________________________ Group or Covering Physicians: _______________________________________________________________________________
_______________________________________________________________________________
CORRESPONDENCE
Please check location where you would like correspondence sent.
Primary
Second
Third
Fourth
All
Other Address_________________________________________________________________________________________
_________________________________________________________________________________________
IF DIFFERENT FROM PRACTICE LOCATIONS:
PHONE NUMBER
FAX NUMBER
E-MAIL
Page 3 of 9
MEDICAL RECORDS
Please check location where you would like medical records requests sent.
Primary
Second
Third
Fourth
Correspondence
Other address _____________________________________________________________________________________________
If different from practice or correspondence located checked above
PHONE NUMBER
FAX NUMBER
EMAIL
SPECIALTY
TYPE OF PROVIDER: PRIMARY CARE PHYSICIAN PHYSICIAN SPECIALIST
BOTH
OTHER SPECIALTY: ________________________
PLEASE LIST PRIMARY AND SUB-SPECIALTIES (as applicable)
BOARD CERTIFIED (ABMS)
Specialty:
Yes No
Sub-Specialty:
Yes No
Sub-Specialty:
Yes No
BOARD CERTIFICATION
(as recognized by American Board of Medical Specialties)
(Please attach a copy of current certification(s).)
PRIMARY SPECIALTY BOARD (ABMS)
DATE CERTIFIED
DATE RECERTIFIED
STATUS/EXP. DATE
SECONDARY SPECIALTY BOARD (ABMS)
DATE CERTIFIED
DATE RECERTIFIED STATUS/EXP. DATE
THIRD SPECIALTY BOARD (ABMS)
DATE CERTIFIED
DATE RECERTIFIED STATUS/EXP. DATE
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 health care organization
Primary Location
Specialty Directory
Sub-specialty Directory
Sub-specialty Directory
Second Location
Specialty Directory
Sub-specialty Directory
Sub-specialty Directory
Third Location
Specialty Directory
Sub-specialty Directory
Sub-specialty Directory
Fourth Location
Specialty Directory
Sub-specialty Directory
Sub-specialty Directory
IF DIFFERENT FROM PRACTICE LOCATIONS:
PHONE NUMBER
FAX NUMBER
E-MAIL
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 4 of 9
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:
HOSPITAL
LOCATION/ADDRESS
TYPE OF PRIVILEGES
EFFECTIVE DATE 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 HAS BEEN COMPLETED, PLEASE ATTACH ON A SEPARATE FORM. MEDICAL/PROFESSIONAL SCHOOL:
CITY
STATE
ZIP
DEGREE INTERNSHIP: INSTITUTION NAME
YEAR OF GRADUATION DATES ATTENDED (MO/YR)
From
To
TYPE OF TRAINING
CITY
STATE
UNIVERSITY AFFILIATION RESIDENCY: INSTITUTION NAME CITY UNIVERSITY AFFILIATION RESIDENCY: INSTITUTION NAME CITY UNIVERSITY AFFILIATION FELLOWSHIP: INSTITUTION NAME CITY
FELLOWSHIP: INSTITUTION NAME CITY
COMPLETED YES NO
TYPE OF RESIDENCY
STATE
COMPLETED YES NO
TYPE OF RESIDENCY
STATE
COMPLETED YES NO
SPECIALTY FIELD
STATE
TYPE OF FELLOWSHIP
SUBSPECIALTY FIELDS
STATE
TYPE OF FELLOWSHIP
DATES ATTENDED (MO/YR)
From
To
Clinical
Research
DATES ATTENDED (MO/YR)
From
To
Clinical
Research
DATES ATTENDED (MO/YR)
From
To
DATES ATTENDED (MO/YR)
From
To
COMPLETED
YES NO
Clinical
Research
DATES ATTENDED (MO/YR)
From
To
COMPLETED
YES NO
Clinical
Research
Page 5 of 9
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