Get La Standardized Credentialing Application 2012-2025

The LA Standardized Credentialing Application is a crucial document for healthcare providers seeking credentialing in Louisiana. This guide provides a step-by-step approach to ensure all necessary sections and fields are completed accurately and effectively.

Follow the steps to fill out the application online:

1. Press the ‘Get Form’ button to acquire the application and open it in your document management tool.
2. Begin by filling out the general information section. Provide your last name, first name, middle name, degree, and any other names you have used. Include your ECFMG number, home address, phone number, and email address, as well as your Social Security number and date of birth.
3. Continue with the primary practice location. Enter the institution or clinic name, tax identification number, and office manager's name. Specify the effective date you began practicing there and provide relevant contact information and addresses.
4. If applicable, complete the second and third practice location sections in the same manner as the primary practice location, ensuring all necessary details are filled out.
5. Fill out the specialty and certification section, indicating the type of provider you are and listing your primary and secondary specialties along with the relevant certification bodies.
6. Complete the education section by listing your medical school, internships, residencies, and fellowships attended, including dates of attendance and whether they were completed.
7. Provide a detailed work history in chronological order, marking any gaps and offering explanations for them where necessary.
8. Enter your professional licenses, including their numbers, dates obtained, and expiration dates, ensuring you attach any relevant copies.
9. List your professional liability insurance coverage details, making sure to attach necessary documentation.
10. Answer the general questions section thoroughly. If you answer 'yes' to any questions, prepare to provide additional explanations.
11. Ensure that all required attachments are included with your submission. This may include licenses, a curriculum vitae, and certificates of insurance.
12. Once all sections have been completed, review the entire application for accuracy. Save any changes, and then download or print your completed application.

Complete your application online to ensure timely processing and avoid delays in credentialing.