Fill in a Valid Louisiana Credentialing Application Template

The Louisiana Credentialing Application form is a standardized document used by healthcare providers to apply for credentialing in the state of Louisiana. Completing this form accurately is essential for ensuring that your credentials are verified and recognized by healthcare organizations. For assistance in filling out the form, please click the button below.

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The Louisiana Credentialing Application form serves as a comprehensive tool for healthcare providers seeking to establish their qualifications and practice locations within the state. This application is meticulously structured to gather essential information, ensuring that all fields are completed in detail. Applicants must provide personal information, including their full name, gender, degrees, and contact details, as well as their Social Security number and date of birth. The form requires specifics about the primary practice location, such as the institution's name, tax identification number, and physical address. Additionally, it includes inquiries about the type of practice—whether solo, multi-specialty, or hospital-based—and the languages spoken at the location. Important considerations regarding accessibility for patients with disabilities, as well as emergency contact arrangements, are also addressed. For those with multiple practice locations, the form allows for the inclusion of up to four sites, with provisions for additional sheets if necessary. Lastly, applicants must indicate their specialties and certifications, as recognized by relevant medical boards, which is crucial for proper directory listing and verification. Completing this application accurately is essential for ensuring compliance with state regulations and facilitating a smoother credentialing process.

Louisiana 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

Click for Louisiana Credentialing Application File

File Breakdown

Fact Name	Description
Form Purpose	The Louisiana Credentialing Application form is designed for healthcare providers seeking credentialing to practice in Louisiana.
Completion Requirements	All sections of the form must be filled out completely. Using phrases like "See C.V." is not acceptable.
Governing Law	This application is governed by Louisiana Revised Statutes Title 37, which regulates the practice of medicine and healthcare professions.
Document Submission	Applicants must attach required documents as listed on page 10 of the application.
Language Requirements	Applicants are encouraged to specify any languages spoken at their practice locations, beyond English.
Accessibility Compliance	The form includes questions to ensure compliance with the Americans with Disabilities Act (ADA) for facilities.

Guide to Using Louisiana Credentialing Application

Completing the Louisiana Credentialing Application form is a straightforward process. This guide will help you fill out the form accurately and efficiently, ensuring that all necessary information is provided. Follow the steps below to complete your application.

General Information: Start by filling in your last name, suffix, first name, and middle name. Indicate your gender and degree. If you have any other names, provide them in the "Any other name" section. Fill in your ECFMG number, UPIN number, and personal details such as your home address, phone number, email, Social Security number, date of birth, and birthplace. Race/ethnicity is voluntary.
Primary Practice Location: Enter the name of your institution or clinic. Provide the office manager's name and tax identification number. Fill in the effective date of your provider status at this location, along with the NPI and EIN. Complete the physical address, contact details, billing address, correspondence address, and medical records address. Specify the type of practice and office hours.
Patient Acceptance: Indicate if you are accepting new patients and specify the age groups you treat. Answer questions regarding staff and facility accessibility, including wheelchair access and services for the disabled. Include your emergency after-hours number and coverage arrangements.
Second Practice Location: Repeat the same steps as in the primary practice location section for your second practice. If you have more than two locations, continue with the same format for the third and fourth locations.
Specialty & Certification: Indicate your type of provider and list your primary and secondary specialties. Attach copies of your current certifications as required.
Directory Information: Check whether your specialties are practiced at each location and indicate if they should be noted in the directory.
PHO / IPA Affiliations: List any PHO’s or IPA’s you participate in, along with the dates of participation.

Once you have completed the application, review it carefully to ensure all sections are filled out correctly. Make sure to attach any required documents and submit the application as instructed. This will help streamline the credentialing process and minimize any delays.

Get Answers on Louisiana Credentialing Application

What is the Louisiana Credentialing Application form used for?

The Louisiana Credentialing Application form is designed for healthcare providers seeking to establish their credentials within the state. It collects essential information about the provider’s qualifications, practice locations, and specialties. Completing this form accurately is crucial for obtaining the necessary approvals to practice medicine in Louisiana.

How should I complete the application form?

When filling out the application, it is important to type or print clearly using black ink. Each section must be completed in full; simply stating “See C.V.” is not acceptable. If you require additional space or have more than four practice locations, attach separate sheets and reference the specific questions. Ensure that all required documents are submitted as outlined on page 10 of the application.

What information is required in the general information section?

The general information section requires various personal details, including:

Full name (including any previous names)
Contact information (address, phone numbers, email)
Social Security Number and date of birth
Gender and race/ethnicity (the latter is voluntary)
Professional credentials (degree, ECFMG number, NPI)

Completing this section accurately is vital as it establishes your identity and qualifications.

What should I include for my practice locations?

For each practice location, you must provide comprehensive details, such as:

Name and type of institution or clinic
Physical address and contact information
Tax Identification Number and effective date of practice
Office hours and types of patients accepted
Accessibility features and arrangements for after-hours coverage

Make sure to indicate if the facility is accessible for individuals with disabilities and if you have arrangements for 24/7 coverage.

Are there any specific documents I need to attach?

Yes, the application requires specific supporting documents. These may include copies of your current certifications, licenses, and any other documents that validate your qualifications and credentials. A detailed list of required documents is provided on page 10 of the application form. Ensure that you include all necessary attachments to avoid delays in processing.

What if I have more than four practice locations?

If you operate in more than four practice locations, you should attach additional sheets with the same information required for each location. Clearly reference the questions from the application to which the additional information pertains. This ensures that your application remains organized and complete.

How long does the credentialing process take?

The timeframe for processing the Louisiana Credentialing Application can vary. Generally, it may take several weeks to a few months, depending on the completeness of your application and the volume of applications being processed at that time. To help expedite the process, ensure that all sections are filled out accurately and that all required documents are submitted with your application.

Common mistakes

Completing the Louisiana Credentialing Application form accurately is crucial for a smooth application process. However, many applicants make common mistakes that can delay their credentialing. Here are seven frequent errors to avoid.

First, applicants often fail to complete all sections of the application. The instructions clearly state that all sections must be completed in their entirety. Simply writing "See C.V." in response to any question is not acceptable. Each section requires specific information that helps verify the applicant's credentials.

Second, misrepresenting personal information can lead to significant issues. For example, providing an incorrect Social Security Number or date of birth can cause delays in processing. Ensure that all personal details are accurate and match official documents.

Third, many applicants neglect to attach required documents. The application specifies that supporting documents must accompany the form. This includes proof of certifications and other relevant paperwork. Missing documents can result in immediate rejection of the application.

Fourth, failing to match the Tax Identification Number (TIN) with IRS records is a common mistake. The application emphasizes that the TIN must match exactly with IRS information. Any discrepancies can lead to complications during verification.

Fifth, applicants frequently overlook the need for clear and legible handwriting or typing. If the application is difficult to read, it may lead to misunderstandings or misinterpretations of the information provided. Use black ink when printing or type the application to ensure clarity.

Sixth, not specifying the correct type of practice can create confusion. The form includes various options, such as "Solo" or "Multi-specialty Group." Selecting the wrong type may affect the applicant's eligibility for certain programs or networks.

Lastly, many applicants forget to indicate their availability for accepting new patients. This information is essential for the credentialing process and impacts the applicant's practice setup. Be sure to select the appropriate option regarding patient acceptance.

By avoiding these common mistakes, applicants can streamline their credentialing process and reduce the likelihood of delays. Attention to detail is essential when completing the Louisiana Credentialing Application form.

Documents used along the form

The Louisiana Credentialing Application form is a critical document for healthcare providers seeking to practice in Louisiana. Alongside this form, several other documents are typically required to ensure a comprehensive review of the applicant's qualifications and background. Below is a list of these additional forms and documents, each serving a specific purpose in the credentialing process.

Curriculum Vitae (CV): This document provides a detailed overview of the applicant's professional history, education, training, and relevant experience in the medical field. It is essential for evaluating the qualifications of the provider.
Proof of Education: Applicants must submit copies of their medical degrees and any relevant certifications. This verifies the educational background and qualifications claimed in the application.
Board Certification Documentation: A copy of current board certifications is required to confirm that the provider meets the standards set by the relevant medical boards.
Malpractice Insurance Certificate: This document proves that the provider has professional liability insurance, which is crucial for protecting against potential claims of negligence.
Criminal Background Check: A report that confirms the absence of any criminal history. This is important for ensuring the safety and trust of patients.
National Provider Identifier (NPI) Number: This number is assigned to healthcare providers and is necessary for billing and identification purposes in the healthcare system.
References: Letters or contact information for professional references who can attest to the applicant's qualifications and character are often required.
State Licensure Verification: Documentation verifying that the applicant holds a valid and current medical license in Louisiana, which is essential for legal practice in the state.

Gathering these documents is a crucial step in the credentialing process. Each one plays a significant role in assessing the qualifications and suitability of healthcare providers, ensuring that they meet the necessary standards to deliver quality care to patients.

Similar forms

The Louisiana Credentialing Application form shares similarities with several other documents commonly used in the healthcare industry. Understanding these similarities can help streamline the application process and ensure that all necessary information is provided. Here are seven documents that are comparable to the Louisiana Credentialing Application form:

National Practitioner Data Bank (NPDB) Report: This document collects information about healthcare practitioners, including malpractice payments and adverse actions. Like the Louisiana application, it requires comprehensive personal and professional details to assess a provider's qualifications.
State Medical License Application: Similar to the Louisiana Credentialing Application, this form requires personal identification, educational background, and professional history. Both documents aim to verify the qualifications and legal standing of medical professionals.
Medicare Enrollment Application (CMS-855): This application is used to enroll healthcare providers in Medicare. It demands detailed information about practice locations and services offered, much like the Louisiana form, which also seeks comprehensive practice-related information.
Insurance Credentialing Application: Health insurance companies use this document to evaluate providers for participation in their networks. It parallels the Louisiana application in that it collects extensive personal and practice information to ensure compliance with network standards.
Hospital Privileges Application: This document is required for healthcare professionals seeking to practice in hospitals. It is similar to the Louisiana Credentialing Application in its thoroughness and the requirement for detailed professional history and qualifications.
Provider Enrollment Application for Medicaid: This application is used to enroll providers in Medicaid programs. Like the Louisiana form, it requires extensive information about the provider's background and practice details to ensure eligibility.
Credentialing Application for Managed Care Organizations: Managed care organizations require this document to assess providers for network inclusion. It shares similarities with the Louisiana application in that both seek detailed information about the provider's qualifications, practice locations, and patient demographics.

Each of these documents serves a critical role in the credentialing process, ensuring that healthcare providers meet the necessary standards to deliver safe and effective care. Familiarity with these forms can aid in the efficient completion of the Louisiana Credentialing Application.

Dos and Don'ts

When filling out the Louisiana Credentialing Application form, it is crucial to follow specific guidelines to ensure accuracy and completeness. Here’s a list of dos and don'ts:

Do type or print your information in black ink.
Do complete all sections in their entirety.
Do provide additional sheets if you need more space or have more than four locations.
Do ensure that your NPI and EIN match the IRS information exactly.
Don't use "See C.V." as a response; it is not acceptable.
Don't leave any required fields blank.
Don't forget to attach copies of any required documents as specified on page 10.

Misconceptions

Misconception 1: The application can be partially completed.

Many believe that they can leave sections of the Louisiana Credentialing Application form blank. In reality, all sections must be completed in their entirety. Simply stating “See C.V.” is not acceptable.

Misconception 2: Additional sheets are not allowed.

Some individuals think they cannot attach extra sheets if they have more than four practice locations. However, the form explicitly states that additional sheets are permitted for this purpose, provided they reference the corresponding questions.

Misconception 3: The form does not require a Social Security Number.

It is a common misunderstanding that the Social Security Number is optional. In fact, it is a required field on the application and must be filled out for processing.

Misconception 4: Only one practice location needs to be listed.

Some applicants assume they can only provide details for a single practice location. The form allows for multiple locations, and all relevant information must be provided for each one.

Misconception 5: The application can be submitted without a current certification.

Applicants often think they can submit the form without including current certification documents. However, the form requires that a copy of current certification(s) be attached, especially for specialties recognized by the American Board of Medical Specialties.

Misconception 6: The application does not require emergency contact information.

Some may believe that emergency after-hours contact details are optional. In reality, providing arrangements for 24/7 coverage is a necessary part of the application process.

Misconception 7: The form does not need to match IRS information.

There is a misconception that the application can contain discrepancies with IRS records. The NPI and Employer Identification Number (EIN) must match IRS information exactly to avoid delays in processing.

Key takeaways

When filling out the Louisiana Credentialing Application form, keep these key points in mind:

Complete All Sections: Ensure every section of the application is filled out completely. Using "See C.V." is not acceptable.
Use Black Ink: Always type or print your responses in black ink to maintain clarity.
Attach Additional Sheets if Necessary: If you have more than four practice locations or need extra space, attach additional sheets and reference the relevant question.
Provide Accurate Tax Information: The Employer Identification Number (EIN) must match the IRS records exactly.
Indicate Practice Type: Clearly specify whether your practice is solo, multi-specialty, or hospital-based, among other options.
Accessibility Information: Be sure to answer questions regarding wheelchair access and compliance with the Americans with Disabilities Act (ADA).
Include Required Documentation: Refer to page 10 for a list of documents that must accompany your application.