Get La Conrad 30 Form 2012-2026

Filling out the LA Conrad 30 Form online is a straightforward process that requires attention to detail and a thorough understanding of the required information. This guide will walk you through each section of the form to ensure that you complete it accurately and efficiently.

Follow the steps to complete the LA Conrad 30 Form online

1. Press the ‘Get Form’ button to obtain a copy of the LA Conrad 30 Form and open it in your online document editor.
2. Begin by entering the name and address of the practice site where the physician will be working.
3. If the employer is different from the practice site, provide the name and address of the employer.
4. Fill out the contact person's name and title, along with their email address, telephone number, and fax number.
5. If applicable, enter the attorney's contact information for the employer.
6. Provide the contact telephone number for the applying practice site, as well as the practice and employer's fax numbers.
7. If the physician has an attorney, enter their name and contact information.
8. Indicate the type of practice by selecting one of the three options: public, non-profit, or for profit.
9. Input the employer’s Medicaid ID number and Medicare ID number.
10. Select the service site type from the options: FQHC, RHC, ambulatory care clinic, SBHC, SRH, CAH, or other.
11. Specify the area of practice for the physician by checking the relevant specialties.
12. Clearly state the advertised salary range for the physician as per the prevailing wage rate.
13. Describe the work schedule including office hours, call coverage, patient load, and any special responsibilities.
14. Provide information about the total number of patients seen at the practice site yearly.
15. Indicate how many patients are uninsured, underinsured, or qualify for a sliding fee scale.
16. Specify the number of patients on Medicaid and Medicare.
17. Confirm whether a sliding fee scale or indigent care policy is in place and detail the relevant information.
18. List the date the sliding fee scale policy was implemented and the percentage of uninsured patients eligible for reduced fees.
19. Explain how the site informs patients about the sliding fee scale or indigent care policy.
20. Complete any additional requirements for specialist positions if applicable, including the Dire Need Criteria form.
21. Once all fields are completed, save your changes, and download or print the form for submission.

Complete your LA Conrad 30 Form online today!