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Blank Louisiana Credentialing Application Form

The Louisiana Credentialing Application form is a standardized document used by healthcare providers to apply for credentialing within various medical institutions and insurance networks in Louisiana. This application ensures that all necessary information is collected and verified, promoting a streamlined process for healthcare professionals seeking to practice in the state. Completing this form accurately is crucial, as it lays the foundation for a provider's ability to deliver care and receive reimbursement for their services.

Outline

The Louisiana Credentialing Application form is an essential document for healthcare providers looking to practice in the state. This form collects a wide range of information to ensure that practitioners meet the necessary standards. It requires basic personal details, such as name, gender, and educational qualifications. Additionally, it asks for contact information, including addresses and phone numbers, which helps establish clear communication channels. The application also covers practice locations, detailing the type of practice, office hours, and whether the facility is accessible to individuals with disabilities. Providers must indicate if they are accepting new patients and specify the age groups they treat. Furthermore, it includes sections for specialty and certification, ensuring that only qualified professionals are recognized. Completing this form accurately is crucial, as incomplete submissions can lead to delays in the credentialing process.

Sample - Louisiana Credentialing Application Form

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

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Form Information

Fact Name	Description
Form Purpose	The Louisiana Credentialing Application is used by healthcare providers to apply for credentialing with insurance companies and healthcare organizations.
Completion Requirement	All sections of the form must be completed in full. Simply writing “See C.V.” is not acceptable.
Governing Laws	The application is governed by Louisiana state regulations regarding healthcare provider credentialing.
Personal Information	Applicants must provide personal details, including name, gender, date of birth, and Social Security Number.
Practice Location	Providers can list up to four practice locations on the application, with the option to attach additional sheets if necessary.
Accessibility Compliance	The form includes questions about compliance with the Americans with Disabilities Act (ADA), ensuring facilities are accessible.
Required Documents	Applicants must refer to page 10 of the application for a comprehensive list of required supporting documents.
Languages Spoken	Providers are encouraged to indicate any languages spoken at their practice locations, enhancing communication with diverse patient populations.

Detailed Guide for Filling Out Louisiana Credentialing Application

Completing the Louisiana Credentialing Application form is an essential step in the credentialing process. This form gathers vital information about your professional background, practice locations, and specialties. After you fill out the form, you will need to submit it along with required documents to the appropriate credentialing authority.

Begin by filling out the General Information section. Include your last name, first name, middle name, suffix, gender, degree, and any other names you have been known by.
Provide your ECFMG number, UPIN number, home address, phone numbers, email address, Social Security number, date of birth, birth place, race/ethnicity (optional), NPI, Individual Medicaid Provider Number, and Medicare Provider Number.
Move to the Primary Practice Location section. Enter the institution or group name, office manager, tax identification number, and the effective date of your provider status at this location.
Fill in the NPI for the group name and ensure it matches IRS records. Then, complete the physical address, office email, website, main phone number, appointment phone number, and fax number.
Provide the billing address where payments should be sent, including contact person details and billing email. Do the same for the correspondence and medical records addresses.
Indicate the type of practice (solo, multi-specialty group, etc.) and specify if you are hospital-employed or healthplan/payor-owned.
Detail your office hours for each day of the week and indicate whether you practice full-time, part-time, or other. List any languages spoken at this location other than English.
Answer questions regarding patient acceptance, age groups treated, and whether PAs or nurse practitioners are used. Also, indicate if the facility is wheelchair accessible and meets ADA requirements.
If applicable, repeat the above steps for the Second, Third, and Fourth Practice Locations. Attach additional sheets if you have more than four locations.
Complete the Specialty & Certification section. List your specialties and attach copies of your current certifications.
Finally, fill out the Directory Information and PHO/IPA Affiliations sections, indicating any relevant specialties practiced at each location and any affiliations you have.

Obtain Answers on Louisiana Credentialing Application

What is the Louisiana Credentialing Application form?

The Louisiana Credentialing Application form is a standardized document that healthcare providers must complete to apply for credentialing in the state of Louisiana. This form collects essential information about the provider’s qualifications, practice locations, and other relevant details necessary for the credentialing process.
Who needs to fill out this application?

All healthcare providers seeking to practice in Louisiana, including physicians, dentists, and other licensed professionals, must complete this application. It is a requirement for obtaining credentialing with healthcare organizations and insurance providers.
What information is required on the application?

The application requires comprehensive information, including:
- Personal details such as name, gender, and date of birth
- Contact information including address, phone numbers, and email
- Practice location details, including the type of practice and office hours
- Specialty and certification information
All sections must be completed in full; simply stating “See C.V.” is not acceptable.
Can I attach additional sheets if I need more space?

Yes, if you need more space for any section or if you have more than four practice locations, you may attach additional sheets. Be sure to reference the specific question you are answering.
What documents must accompany the application?

A list of required documents is provided on page 10 of the application. Commonly required documents include copies of licenses, certifications, and proof of malpractice insurance. Make sure to review this list carefully to ensure your application is complete.
How do I submit the application?

The completed application can typically be submitted electronically or by mail, depending on the specific instructions provided by the credentialing organization. Check the submission guidelines carefully to ensure proper delivery.
What if I make a mistake on the application?

If you realize you made a mistake after submitting the application, contact the credentialing office as soon as possible. They will guide you on how to correct the error and whether a resubmission is necessary.
How long does the credentialing process take?

The duration of the credentialing process can vary. Generally, it may take anywhere from a few weeks to several months, depending on the organization’s policies and the completeness of your application. Stay in touch with the credentialing office for updates.
Is there a fee associated with the application?

Some organizations may charge a fee for processing the credentialing application. It’s important to check the specific requirements of the organization to which you are applying.
What happens after I submit my application?

After submission, the credentialing office will review your application and supporting documents. They may contact you for additional information or clarification. Once the review is complete, you will be notified of the outcome.

Common mistakes

Filling out the Louisiana Credentialing Application form can be a complex task. Many applicants make common mistakes that can delay the process or lead to rejections. Here are nine frequent errors to avoid.

First, failing to complete all sections of the application is a critical mistake. The form clearly states that **all sections must be completed in their entirety**. Leaving any section blank, even if it seems irrelevant, can result in delays or denial of your application.

Second, using phrases like “See C.V.” instead of providing complete information is unacceptable. The application requires specific details. Always provide the requested information directly on the form.

Third, not matching the Employer Identification Number (EIN) with IRS records can cause issues. This number must be accurate and consistent. Discrepancies can lead to complications in processing your application.

Fourth, neglecting to provide correct contact information for billing and correspondence can create unnecessary confusion. Ensure that all addresses, phone numbers, and emails are accurate and up to date.

Fifth, omitting required documents is another common pitfall. Always refer to the list of required documents on page 10 of the application. Submitting an incomplete application can cause delays.

Sixth, misrepresenting your practice type or specialty can have serious consequences. Be honest and precise about your qualifications and the type of practice you are involved in. Misleading information can lead to legal repercussions.

Seventh, not specifying languages spoken at your practice location is a mistake that can limit patient access. If you or your staff speak other languages, include this information to enhance communication with patients.

Eighth, failing to indicate whether your facility meets the Americans with Disabilities Act (ADA) requirements can lead to compliance issues. This information is vital for ensuring accessibility for all patients.

Ninth, neglecting to provide emergency after-hours contact information can hinder patient care. Always include a reliable contact number for after-hours emergencies to ensure continuous patient support.

By avoiding these mistakes, you can streamline the credentialing process and ensure that your application is processed efficiently. Take the time to review your application thoroughly before submission.

Documents used along the form

The Louisiana Credentialing Application form is a critical document for healthcare providers seeking to establish their credentials within the state. However, this application is often accompanied by several other important forms and documents that provide additional information about the applicant's qualifications and practice. Below are four commonly used documents that complement the Louisiana Credentialing Application.

Curriculum Vitae (C.V.): This document outlines the applicant's educational background, work experience, certifications, and professional achievements. It provides a comprehensive overview of the provider's qualifications and is essential for credentialing purposes.
Proof of Board Certification: A copy of the current certification from the American Board of Medical Specialties or another recognized certifying body is often required. This document verifies that the provider has met specific standards in their specialty and is crucial for demonstrating competency in their field.
Malpractice Insurance Documentation: This document serves as evidence that the provider carries malpractice insurance. It typically includes the insurance policy number, coverage limits, and the effective dates of the policy, ensuring that the provider is protected against potential claims.
State Licensure Verification: A copy of the provider's current state medical license is necessary to confirm that they are legally permitted to practice in Louisiana. This verification helps ensure compliance with state regulations and standards for healthcare providers.

These documents, along with the Louisiana Credentialing Application form, create a comprehensive profile of the healthcare provider. Together, they facilitate the credentialing process, allowing healthcare organizations to assess the qualifications and competencies of applicants effectively.

Similar forms

The Louisiana Credentialing Application form shares similarities with several other important documents used in healthcare credentialing. Here’s a look at nine of those documents and how they relate:

California Credentialing Application: Like the Louisiana form, this application requires detailed personal and practice information, ensuring that all sections are fully completed for review.
Texas Medical License Application: Both documents demand comprehensive background details, including education, training, and practice locations, to verify the qualifications of healthcare providers.
Florida Medical Board Application: Similar to the Louisiana application, this form asks for information on specialties and certifications, helping to assess the applicant's expertise in their field.
New York State Credentialing Application: This application also emphasizes the need for complete information and supporting documents, ensuring no section is left unanswered.
National Provider Identifier (NPI) Application: Both forms require personal identification details, including Social Security numbers and practice addresses, to maintain accurate records of healthcare providers.
Medicare Enrollment Application: This document, like the Louisiana application, collects extensive information about practice locations and services offered, which is essential for reimbursement processes.
Credentialing Application for Managed Care Organizations: Similar in purpose, this application focuses on gathering provider information to determine eligibility for participation in managed care networks.
Joint Commission Credentialing Application: This application seeks similar details about healthcare providers, ensuring compliance with standards for quality and safety in patient care.
Insurance Credentialing Application: Both documents require a thorough disclosure of practice information, including billing addresses and contact details, to facilitate the credentialing process with insurance providers.

Dos and Don'ts

When filling out the Louisiana Credentialing Application form, consider the following tips to ensure a smooth process:

Do complete all sections of the application. Leaving any section blank may lead to delays.
Do use black ink or type your responses. This ensures clarity and legibility.
Do attach additional sheets if you need more space for your answers. Reference the specific question you are addressing.
Do provide accurate information. Double-check all details, especially your Tax Identification Number and NPI.
Don't use "See C.V." in place of answering questions. Each section must be filled out completely.
Don't forget to review the required documents on page 10 before submitting your application.

Misconceptions

When it comes to the Louisiana Credentialing Application form, misunderstandings can lead to unnecessary complications. Here are seven common misconceptions about this important document:

All sections can be left blank if not applicable. Many believe that if a section does not apply to them, it can simply be skipped. However, every section must be completed in its entirety. Simply stating "N/A" or "See C.V." is not acceptable.
Only physicians need to fill out this form. While it is primarily used by physicians, other healthcare providers, such as nurse practitioners and physician assistants, may also need to complete it. Understanding who needs to apply is crucial.
Submitting the form electronically is always an option. Some assume that they can submit the application online. In many cases, the form must be printed, filled out, and submitted in person or via mail. Always check the specific submission requirements.
Previous experience is not relevant. Some applicants think that only current information matters. However, detailing past practice locations and experiences can enhance your application and provide a fuller picture of your qualifications.
There are no consequences for incomplete applications. Many underestimate the importance of thoroughness. Submitting an incomplete application can lead to delays or outright denial of credentialing. Attention to detail is key.
Once submitted, the application cannot be changed. Some believe that they cannot make any updates after submission. In reality, if any information changes, it’s important to notify the credentialing body promptly to avoid issues.
The application process is quick and straightforward. While some may expect a fast turnaround, credentialing can be a lengthy process. It often involves verification of credentials and background checks, which can take time.

Understanding these misconceptions can help streamline the credentialing process and ensure a smoother experience for all healthcare providers involved.

Key takeaways

When filling out the Louisiana Credentialing Application form, consider the following key points:

Complete All Sections: Ensure every section of the application is filled out completely. Simply writing “See C.V.” is not acceptable.
Use Clear Writing: Type or print your responses in black ink. This helps maintain clarity and professionalism.
Provide Accurate Information: Double-check that all information, especially names and numbers, matches exactly with IRS records and other official documents.
Attach Additional Sheets if Necessary: If you have more than four practice locations or need extra space for responses, attach additional sheets and reference the specific question.
Required Documents: Review the list of required documents on page 10 of the application to ensure you submit everything needed for processing.