Fill in a Valid La Standardized Credentialing Application Template

The Louisiana Standardized Credentialing Application form is a comprehensive document used for credentialing healthcare providers in the state of Louisiana. This application ensures that all necessary information is collected in a uniform manner, facilitating the review process by healthcare organizations. For healthcare professionals looking to streamline their credentialing, filling out this form comprehensively is crucial; start the process by clicking the button below.

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The Louisiana Standardized Credentialing Application (LSCA) is a comprehensive form designed for healthcare providers seeking to streamline their credentialing process. This application requires detailed information to assess and verify the qualifications of medical professionals. Providers must fill out sections including general information—such as name, degrees, and contact details—and specifics about their practice locations. Each primary practice must provide data on its institution, services, and accessibility options. Furthermore, providers must detail their specialties and certifications, ensuring they are recognized by relevant medical boards. Important compliance inquiries, like ADA accessibility and patient acceptance policies, also form critical sections of this application. While completing this form, it's essential to adhere to the instruction of providing thorough responses on each section, as partial answers, such as “See C.V.”, will not suffice. Alongside the LSCA, applicants need to submit supporting documentation as listed on the provided checklist. This thoroughness ultimately aids in establishing a trusted healthcare environment for patients across Louisiana.

La Standardized Credentialing Application 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

Click for La Standardized Credentialing Application File

File Breakdown

Fact Name	Details
Completeness Requirement	All sections of the Louisiana Standardized Credentialing Application must be completed in full. Responses such as "See C.V." are not acceptable.
Document Submission	Applicants must attach a list of required documents, as specified on page 10 of the form, to support their application.
Accessibility Compliance	Practices must confirm compliance with the Americans with Disabilities Act (ADA) requirements to ensure that facilities are accessible.
Applicable Governing Laws	The Louisiana Standardized Credentialing Application is governed by state laws, including Louisiana Revised Statutes and regulations from the Louisiana State Board of Medical Examiners.

Guide to Using La Standardized Credentialing Application

Completing the Louisiana Standardized Credentialing Application form is an important step in the credentialing process. After filling out this form accurately, ensure all required documents are gathered as specified on the form. Here are the steps to follow for proper completion.

Begin with the General Information section. Enter your last name, first name, middle name, and suffix (if applicable). Select your gender and fill in your degree. If you have any other names, include them as well.
Provide your ECFMG and UPIN numbers, if applicable. Fill out your home address, including street address, city, state, and zip code. Include your home phone number and pager or answering service number.
Optional: Supply your home email address. Enter your social security number, date of birth, place of birth, race/ethnicity (this is voluntary), NPI, Medicaid provider number, and Medicare provider number.
Complete the Primary Practice Location section. Fill in the institution or clinic name, office manager, and tax identification number. Provide the effective date of your provider status at this location. Include the NPI for the group as registered with the IRS.
Complete the physical address, office email, website, main phone number, appointment phone number, and fax number. Provide the billing address and contact person for billing along with their phone number, city, state, zip code, email, and fax number.
Enter the correspondence address with similar contact details. Do the same for the medical records address.
Select the type of practice you will be working in. Indicate if you are full-time, part-time, or working in another capacity. Describe the languages spoken at the practice other than English.
Circle whether you are accepting new patients and indicate the age groups you treat. Answer questions related to the accessibility of the facility and services offered for those with disabilities. Ensure to fill in the emergency after-hours number and coverage arrangements.
If you have additional practice locations, repeat the steps above for each location in the designated sections. Attach additional sheets if necessary.
Fill out the Specialty & Certification section, including your primary and secondary specialties, along with the certifying bodies. Attach copies of your current certifications as required.
Lastly, complete the Directory Information to indicate specialization at each location. This helps to ensure accurate representation in directories.

Get Answers on La Standardized Credentialing Application

What is the purpose of the Louisiana Standardized Credentialing Application form?

The Louisiana Standardized Credentialing Application form is designed to streamline the credentialing process for healthcare providers. It provides essential information needed by healthcare organizations to verify the qualifications and status of practitioners seeking to join their network. By using this standardized form, the process becomes more efficient for both the providers and the institutions involved.

How should I complete the application form?

When filling out the application, it is important to type or print your answers in black ink. Ensure that you complete all sections thoroughly. Simply writing "See C.V." is not acceptable; every section must have the required information. If you need additional space or if you practice at more than four locations, include extra sheets and reference the specific questions as necessary.

What documents are required to submit along with the application?

Page 10 of the application lists all the required documents that must accompany your submission. This typically includes proof of identity, relevant licenses, and certifications. Make sure to review this closely to avoid any delays in the processing of your application.

Yes, the application includes a section where you will be asked to provide your Social Security Number. This is important for identification purposes and to facilitate the verification process by credentialing organizations.

What information should I include about my practice location?

You need to provide detailed information about your primary practice location and any additional locations. This includes the name of the institution or clinic, physical address, contact information, and your role at that location (full-time or part-time). If you operate in multiple locations, similar details are required for each one.

Are there specific accessibility requirements I should be aware of?

Yes, the application includes questions regarding ADA compliance and accessibility features at your practice locations. This is to ensure your practice is accessible to all patients, including those with disabilities. Indicate if your facility meets these requirements and if services for the disabled are available, such as wheelchair access or sign language interpretation.

What should I know about specialty and certification information?

You will need to provide information about your specialty and any board certifications. It is crucial to attach copies of your current certifications to support your application. Also, you may need to indicate at which locations you practice each specialty, as this information can affect your listing in directories used by healthcare organizations.

Is there a deadline for submitting my application?

While specific deadlines may vary based on the institution or organization you’re applying to, you should submit your application as soon as possible to avoid delays. Check with the specific entity you are applying to for their timelines and any policies regarding application processing.

Whom should I contact if I have questions during the application process?

If you have any questions or need assistance while completing the application, contact the credentialing department of the healthcare organization where you are applying. They can provide guidance tailored to their specific processes and requirements.

Common mistakes

Filling out the Louisiana Standardized Credentialing Application form accurately is crucial for ensuring that healthcare providers can practice without delays or issues. One major mistake applicants often make is **leaving sections incomplete**. Each part of the application must be filled out in its entirety. Simply writing “See C.V.” in place of a required answer is unacceptable. Make sure to provide all necessary information to avoid any potential processing delays.

Another common error involves failing to adhere to the formatting guidelines specified in the directions. Applicants should type or print in black ink when completing the form. Using another color or format can lead to a rejection of the application, prompting applicants to start the process all over again.

In addition, many individuals forget to double-check the accuracy of their **tax identification number (TIN)**. This number must match exactly with the information registered with the IRS. If there is any discrepancy, it can significantly delay credentialing, which may affect the provider's ability to receive payments from Medicare or Medicaid.

Beyond these issues, applicants frequently overlook the importance of providing **correct practice location information**. Each practice location needs accurate details regarding the institution's name, physical address, and contact numbers. Incomplete or incorrect location data can result in unnecessary confusion and hinder patient access to services.

One mistake that can easily be overlooked is failing to indicate the **type of practice** accurately. Whether the provider works in a solo practice or part of a group setting can impact contract negotiations and arrangements with health plans. Being clear about the type of practice helps streamline the overall credentialing process.

Lastly, applicants sometimes neglect to consider their **emergency after-hours coverage** arrangements. It is essential to specify how 24/7 coverage will be provided. This detail not only enhances patient safety but is often a requirement expected by the organizations reviewing the application.

By avoiding these common mistakes, applicants can facilitate a smoother credentialing process. Attention to detail is paramount in achieving timely approval and ensuring continuous care for patients.

Documents used along the form

The Louisiana Standardized Credentialing Application form is an essential document that helps healthcare providers detail their qualifications and practice information. Alongside this form, there are several other important documents that may be required during the credentialing process. Below are some of those forms and documents, each described briefly.

Curriculum Vitae (C.V.): The C.V. provides a comprehensive overview of a provider's educational background, work history, and professional accomplishments. It often includes information on previous positions held, certifications, and relevant training.
State Licensure Verification: This document confirms that the healthcare provider holds a valid state license to practice within Louisiana. It ensures compliance with state regulations and can include license numbers and expiration dates.
Malpractice Insurance Certificate: This certificate serves as proof that the provider has appropriate malpractice coverage. It details the policy limits, coverage dates, and the insurance company's contact information.
National Provider Identifier (NPI) Confirmation: Confirmation of the NPI is necessary to verify the provider’s unique identification number in the healthcare system. This number is crucial for billing and other administrative functions.
Board Certification Documentation: This documentation demonstrates that the provider has achieved certification in their specialty by the appropriate medical board. It typically includes the board’s name, the specialty area, and the effective dates of certification.

These documents support the credentialing process and ensure that healthcare providers meet the necessary standards for practice. Properly completing and submitting these forms helps facilitate timely credentialing and enhances the quality of healthcare services.

Similar forms

National Practitioner Data Bank (NPDB) Application: Similar to the La Standardized Credentialing Application, the NPDB application requires personal identification information, practice locations, and details on professional history. Both documents serve to verify credentials and ensure compliance with established standards.
State Licensing Application: Like the La Standardized Credentialing Application, a state licensing application necessitates comprehensive personal and professional information, including education and training history. Both forms are crucial for obtaining the necessary permissions to practice legally.
Medicare Enrollment Form: This form is parallel to the La Standardized Credentialing Application as it requires providers to submit their practice information, verification of qualifications, and other essential details pertinent for participation in Medicare programs.
Medicaid Provider Enrollment Form: Similar to the Louisiana credentials application, this form collects essential information about healthcare providers, including personal identification, practice locations, and payer information, facilitating their enrollment in Medicaid services.
Hospital Privilege Application: This application, like the La Standardized Credentialing Application, demands detailed information on qualifications, professional history, and practice affiliations to grant medical staff privileges within a hospital or medical facility.
Credentialing Application for Insurance Panels: Similarity includes the collection of practice details, specialties, and provider identification. This application ensures that healthcare providers meet standards set by insurance companies before participation in their networks.
Joint Commission Credentialing Application: Resembling the La application, this document encompasses a thorough review of a provider’s credentials, including training, licenses, and practice history, which helps organizations achieve accreditation from the Joint Commission.

Dos and Don'ts

When filling out the Louisiana Standardized Credentialing Application form, attention to detail is essential. Here are key points to consider:

Do complete all sections fully. Leaving sections blank is not acceptable.
Do type or print clearly in black ink to ensure readability.
Do provide additional sheets if needed, and reference the specific question.
Do attach required documents as listed on page 10 and ensure accuracy in information provided.
Don't use “See C.V.” or similar phrases in the application; every section requires full information.
Don't forget to confirm that names or identifiers match exactly with IRS information, especially the Tax Identification Number.
Don't submit the form without reviewing it for any errors or omissions that could delay the processing.

Misconceptions

Misconception: The application can be partially completed. All sections of the La Standardized Credentialing Application must be filled out completely. Responses such as “See C.V.” are not acceptable.
Misconception: Handwritten submissions are acceptable. The application must be typed or printed in black ink. This ensures clarity and uniformity in documentation.
Misconception: The application can be submitted without required documents. Along with the completed application, required documents must also be submitted. Check the list on page 10 for detailed requirements.
Misconception: You can skip non-mandatory questions. While some questions are marked as voluntary, skipping them may create delays or concerns during the review process.
Misconception: Multiple practice locations can be entered without limits. If there are more than four practice locations, additional sheets must be attached. Each location must provide complete information.
Misconception: Accessibility information is optional. The application includes several questions regarding facility accessibility, which must be answered to comply with the requirements of the Americans with Disabilities Act (ADA).
Misconception: Age groups and patient acceptance statuses can be vague. Specific options must be selected for the age group(s) treated and whether new patients are accepted. This helps identify the provider’s practice focus.
Misconception: The structure of the information doesn’t need to match IRS documentation. It is crucial that the Employer Identification Number (EIN) and the NPI Group Name match exactly with IRS information to avoid discrepancies.

Key takeaways

When filling out the Louisiana Standardized Credentialing Application form, keep the following key takeaways in mind:

Complete Every Section: All sections must be filled out completely. Simply writing "See C.V." is not acceptable.
Use Black Ink: Always type or print your responses using black ink for clarity.
Documentation: Refer to page 10 of the application for a list of required documents that must accompany your application.
Accurate Information: Ensure that information such as the Employer Identification Number (EIN) matches exactly with IRS records to avoid processing delays.
Emergency Coverage: Provide details about after-hours coverage and collaborating physicians, as this is crucial for patient care continuity.
Accessibility Features: Include whether your practice location meets the Americans with Disabilities Act (ADA) requirements, as this information is vital for compliance.
Practice Locations: If you have more than four practice locations, attach additional sheets with the same information requested in the form.
Signature Requirement: Don't forget to sign and date the application before submission to validate your information.

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Get Answers on La Standardized Credentialing Application

What is the purpose of the Louisiana Standardized Credentialing Application form?

How should I complete the application form?

What documents are required to submit along with the application?

Can I provide my Social Security Number on the form?

What information should I include about my practice location?

Are there specific accessibility requirements I should be aware of?

What should I know about specialty and certification information?

Is there a deadline for submitting my application?

Whom should I contact if I have questions during the application process?

Common mistakes

Documents used along the form

Similar forms

Dos and Don'ts

Misconceptions

Key takeaways