The Texas Credentialing Application form is a standardized document used by healthcare professionals seeking to become credentialed with insurance carriers in Texas. Developed by the Texas Department of Insurance, this application collects essential information regarding an individual's professional qualifications, work history, and affiliations. Completing this form accurately is crucial for ensuring a smooth credentialing process and facilitating access to necessary healthcare services.
The Texas Credentialing Application form, officially known as LHL234, is an essential document for healthcare professionals seeking to establish their credentials with insurance carriers in Texas. This standardized application, as mandated by the Texas Department of Insurance, collects comprehensive information about the applicant's personal details, education, and professional history. The form begins by asking for individual information such as the applicant's name, contact details, and social security number. It then delves into educational background, requiring details about professional degrees and any postgraduate training. Licenses and certifications are also crucial components, with applicants needing to list all licenses held in various states, including expiration dates and DEA numbers. Additionally, the form covers professional specialties, work history, hospital affiliations, and references, ensuring a thorough review of the applicant's qualifications. Finally, it addresses professional liability insurance coverage, which is vital for assessing risk and ensuring compliance with industry standards. Completing this form accurately is vital for healthcare professionals aiming to provide services under various insurance plans in Texas.
LHL234 | 01/07
Texas Standardized Credentialing Application
Pursuant to Texas Insurance Code § 1452.052, LHL234 Rev. 01/07 is promulgated by the Texas Department of Insurance. Please send this application to the carrier with whom you wish to become credentialed.
Section I-Individual Information
TYPE OF PROFESSIONAL
LAST NAME
FIRST
MIDDLE
(JR., SR., ETC.)
MAIDEN NAME
YEARS ASSOCIATED (YYYY-YYYY)
OTHER NAME
HOME MAILING ADDRESS
CITY
STATE/COUNTRY
POSTAL CODE
HOME PHONE NUMBER
SOCIAL SECURITY NUMBER
Female
Male
CORRESPONDENCE ADDRESS
PHONE NUMBER
FAX NUMBER
E-MAIL
DATE OF BIRTH (MM/DD/YYYY)
PLACE OF BIRTH
CITIZENSHIP
IF NOT AMERICAN CITIZEN, VISA NUMBER & STATUS
ARE YOU ELIGIBLE TO WORK IN THE UNITED STATES?
Yes No
U.S.MILITARY SERVICE/PUBLIC HEALTH
DATES OF SERVICE (MM/DD/YYYY) TO
LAST LOCATION
Yes
No
(MM/DD/YYYY)
BRANCH OF SERVICE
ARE YOU CURRENTLY ON ACTIVE OR RESERVE MILITARY DUTY?
Education
PROFESSIONAL DEGREE (MEDICAL, DENTAL, CHIROPRACTIC, ETC.)
Issuing Institution:
ADDRESS
DEGREE
ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
Please check this box and complete and submit Attachment A if you received other professional degrees.
POST-GRADUATE EDUCATION
SPECIALTY
Internship
Residency
Fellowship
Teaching Appointment
INSTITUTION
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
Program successfully completed
PROGRAM DIRECTOR
CURRENT PROGRAM DIRECTOR (IF KNOWN)
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Education - continued
Please check this box and complete and submit Attachment B if you received additional postgraduate training.
OTHER GRADUATE-LEVEL EDUCATION
Licenses and Certificates - Please include all license(s) and certifications in all States where you are currently or have previously been licensed.
LICENSE TYPE
LICENSE NUMBER
STATE OF REGISTRATION
ORIGINAL DATE OF ISSUE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
DO YOU CURRENTLY PRACTICE IN THIS STATE?
DEA Number:
DPS Number:
OTHER CDS (PLEASE SPECIFY)
NUMBER
UPIN
NATIONAL PROVIDER IDENTIFIER (WHEN AVAILABLE)
ARE YOU A PARTICIPATING MEDICARE PROVIDER?
ARE YOU A PARTICIPATING MEDICAID PROVIDER?
Medicare Provider Number:
Medicaid Provider Number:
EDUCATIONAL COUNCIL FOR FOREIGN MEDICAL GRADUATES (ECFMG)
ECFMG ISSUE DATE (MM/DD/YYYY)
N/A
No ECFMG Number:
Professional/Specialty Information
PRIMARY SPECIALTY
BOARD CERTIFIED?
Name of Certifying Board:
INITIAL CERTIFICATION DATE (MM/YYYY)
RECERTIFICATION DATE(S), IF APPLICABLE (MM/YYYY)
EXPIRATION DATE, IF APPLICABLE (MM/YYYY)
IF NOT BOARD CERTIFIED, INDICATE ANY OF THE FOLLOWING THAT APPLY.
I have taken exam, results pending for
Board.
I have taken Part I and am eligible for Part II of the
Exam.
I am intending to sit for the Boards on
(date)
I am not planning to take Boards.
DO YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY?
HMO:
No PPO: Yes No
POS:
SECONDARY SPECIALTY
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Professional/Specialty Information -continued
No PPO:
ADDITIONAL SPECIALTY
PLEASE LIST OTHER AREAS OF PROFESSIONAL PRACTICE INTEREST OR FOCUS (HIV/AIDS, ETC.)
Work History - Please provide a chronological work history. You may submit a Curriculum Vitae as
a supplement. Please explain all gaps in employment that lasted more than six months.
CURRENT PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
PREVIOUS PRACTICE/EMPLOYER NAME
REASON FOR DISCONTINUANCE
PLEASE PROVIDE AN EXPLANATION FOR ANY GAPS GREATER THAN SIX MONTHS (MM/YYYY TO MM/YYYY) IN WORK HISTORY.
Gap Dates:
Explanation:
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Work History – continued
Please check this box and complete and submit Attachment C if you have additional work history
Hospital Affiliations-Please include all hospitals where you currently have or have previously had privileges.
DO YOU HAVE HOSPITAL PRIVILEGES?
IF YOU DO NOT HAVE ADMITTING PRIVILEGES, WHAT ADMITTING ARRANGEMENTS DO YOU HAVE?
PRIMARY HOSPITAL WHERE YOU HAVE ADMITTING PRIVILEGES
START DATE (MM/YYYY)
FAX
FULL UNRESTRICTED PRIVILEGES?
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.)
ARE PRIVILEGES TEMPORARY?
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO PRIMARY HOSPITAL?
OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?
Please check this box and complete and submit Attachment D if you have additional current hospital affiliations.
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES
AFFILIATION DATES (MM/YYYY TO
MM/YYYY)
WERE PRIVILEGES TEMPORARY?
Please check this box and complete and submit Attachment E if you have additional previous hospital affiliations.
References-Please provide three peer references from the same field and/or specialty who are not partners in your own group practice and are not relatives. All peer references should have firsthand knowledge of your abilities.
1 NAME/TITLE
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References- continued
2NAME/TITLE
3NAME/TITLE
CITYSTATE/COUNTRYPOSTAL CODE
Professional Liability Insurance Coverage
SELF-INSURED?
NAME OF CURRENT MALPRACTICE INSURANCE CARRIER OR SELF-INSURED ENTITY
POLICY NUMBER
EFFECTIVE DATE (MM/DD/YYYY)
AMOUNT OF COVERAGE PER
AMOUNT OF COVERAGE AGGREGATE
TYPE OF COVERAGE
LENGTH OF TIME WITH CARRIER
OCCURRENCE
Individual
Shared
NAME OF PREVIOUS MALPRACTICE INSURANCE CARRIER IF WITH CURRENT CARRIER LESS THAN 5 YEARS
Call Coverage
See attached list of hospital staff within my department I utilize for call coverage.
PLEASE LIST NAMES OF COLLEAGUE(S) PROVIDING REGULAR COVERAGE AND HIS OR HER SPECIALTIES.
Name:
Specialty:
PLEASE LIST FULL NAMES OF ALL PARTNERS IN YOUR PRACTICE. CHECK THIS BOX AND ATTACH LIST FOR LARGE GROUP.
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Practice Location Information - Please answer the following questions for each practice location. Use Attachment F or
PRACTICE LOCATION
make copies of pages 6-7 as necessary.
of
TYPE OF SERVICE PROVIDED
Solo Primary Care
Solo Specialty Care
Group Primary Care
Group Single Specialty
Group Multi-Specialty
GROUP NAME/PRACTICE NAME TO APPEAR IN THE DIRECTORY
GROUP/CORPORATE NAME AS IT APPEARS ON IRS W-9
PRACTICE LOCATION ADDRESS
Primary
BACK OFFICE PHONE NUMBER
SITE-SPECIFIC MEDICAID NUMBER
TAX ID NUMBER
GROUP NUMBER CORRESPONDING TO TAX ID NUMBER
GROUP NAME CORRESPONDING TO TAX ID NUMBER
ARE YOU CURRENTLY PRACTICING AT THIS LOCATION?
IF NO, EXPECTED START DATE? (MM/DD/YYYY)
DO YOU WANT THIS LOCATION LISTED IN THE
DIRECTORY?
OFFICE MANAGER OR STAFF CONTACT
CREDENTIALING CONTACT
BILLING COMPANY'S NAME (IF APPLICABLE)
BILLING REPRESENTATIVE
DEPARTMENT NAME IF HOSPITAL-BASED
CHECK PAYABLE TO
CAN YOU BILL ELECTRONICALLY?
HOURS PATIENTS ARE SEEN
Monday
No Office Hours
Morning:
Afternoon:
Evening:
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
DOES THIS LOCATION PROVIDE 24 HOUR/7 DAY A WEEK PHONE COVERAGE?
Answering Service
Voice mail with instructions to call answering service
Voice mail with other instructions
None
THIS PRACTICE LOCATION ACCEPTS
all new patients
existing patients with change of payor
new patients with referral
new Medicare patients
new Medicaid patients
IF NEW PATIENT ACCEPTANCE VARIES BY HEALTH PLAN, PLEASE PROVIDE EXPLANATION.
PRACTICE LIMITATIONS
Male only
Female only
Age:
Other:
DO NURSE PRACTITIONERS, PHYSICIAN ASSISTANTS, MIDWIVES, SOCIAL WORKERS OR OTHER NON-PHYSICIAN PROVIDERS CARE FOR PATIENTS AT THIS PRACTICE
LOCATION?
If yes, provide the following information for each staff member:
NAME
PROFESSIONAL DESIGNATION
STATE & LICENSE NO.
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Practice Location Information - continued
NON-ENGLISH LANGUAGES SPOKEN BY HEALTH CARE PROVIDERS
NON-ENGLISH LANGUAGES SPOKEN BY OFFICE PERSONNEL
ARE INTERPRETERS AVAILABLE?
No If yes, please specify languages:
DOES THIS PRACTICE LOCATION MEET ADA ACCESSIBILITY STANDARDS?
WHICH OF THE FOLLOWING FACILITIES ARE HANDICAPPED ACCESSIBLE?
Building
Parking Restroom
DOES THIS LOCATION HAVE OTHER SERVICES FOR THE DISABLED?
Text Telephony-TTY
American Sign Language-ASL
Mental/Physical Impairment Services
0ther:
IS THIS LOCATION ACCESSIBLE BY PUBLIC TRANSPORTATION?
Bus
Regional Train
DOES THIS LOCATION PROVIDE CHILDCARE SERVICES?
DOES THIS LOCATION QUALIFY AS A MINORITY BUSINESS ENTERPRISE?
WHO AT THIS LOCATION HAVE THE FOLLOWING CURRENT CERTIFICATIONS? (PLEASE LIST ONLY THE APPLICANT'S CERTIFICATION EXPIRATION DATES.)
Basic Life Support
Staff
Provider Exp:
Advanced Life Support in OB
Advanced Trauma Life Support
Cardio-Pulmonary Resuscitation
Advanced Cardiac Life Support
Pediatric Advanced Life Support
Neonatal Advanced Life Support
Other (please specify)
DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE?
Laboratory Services; please list all Certificates of Participation (CLIA, AAFP, COLA, CAP, MLE):
X-ray; please list all certifications:
OTHER SERVICES
Radiology Services
EKG
Care of Minor Lacerations
Pulmonary Function Tests
Allergy Injections
Allergy Skin Tests
Routine Office Gynecology
Drawing Blood
Age Appropriate Immunizations
Flexible Sigmoidoscopy
Tympanometry/Audiometry Tests
Asthma Treatments
Osteopathic Manipulations
IV Hydration /Treatments
Cardiac Stress Tests
Physical Therapies
PLEASE LIST ANY ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)
IS ANESTHESIA ADMINISTERED AT THIS PRACTICE LOCATION?
WHO ADMINISTERS IT?
No Please specify the classes or categories:
Please check this box and complete and submit Attachment F if you have other practice locations.
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Section II-Disclosure Questions - Please provide an explanation for any question answered yes-except 16-on page 10.
Licensure
1Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, or have you ever been subject to a consent order, probation or any conditions or limitations by any state licensing board?
2
Have you ever received a reprimand or been fined by any state licensing board?
Hospital Privileges and Other Affiliations
3Have your clinical privileges or Medical Staff membership at any hospital or healthcare institution ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical records when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board?
4Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?
5Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)?
Education, Training and Board Certification
6Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign?
7Have you ever, while under investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?
8Have any of your board certifications or eligibility ever been revoked?
9Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?
DEA or DPS
10Have your Federal DEA and/or DPS Controlled Substances Certificate(s) or authorization(s) ever been denied, suspended, revoked, restricted, denied renewal, or voluntarily relinquished?
Medicare, Medicaid or other Governmental Program Participation
11Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs?
Other Sanctions or Investigations
12Are you currently or have you ever been the subject of an investigation by any hospital, licensing authority, DEA or DPS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program?
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Section II - Disclosure Questions - continued
13To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?
14Have you ever received sanctions from or been the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)?
15Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation by a hospital or healthcare facility of any military agency?
Malpractice Claims History
16Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?
If yes, please check this box and complete and submit Attachment G.
Criminal
17Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony that is reasonably related to your qualifications, competence, functions, or duties as a medical professional?
18Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony including an act of violence, child abuse or a sexual offense?
19Have you been court-martialed for actions related to your duties as a medical professional?
Ability to Perform Job
20Are you currently engaged in the illegal use of drugs? ("Currently" means sufficiently recent to justify a reasonable belief that the use of drug may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22. It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription controlled substances.)
21Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety?
22Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients?
23Are you unable to perform the essential functions of a practitioner in your area of practice, with or without reasonable accommodation?
Please use the space on page 10 to explain yes answers to any question except #16.
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Section II - Disclosure Questions-continued
Please use the space below to explain yes answers to any question except 16.
QUESTION NUMBER PLEASE EXPLAIN
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Trec 1-4 - Specifications regarding the property's condition, including environmental considerations and construction documents, are laid out to inform the buyer and protect both parties’ interests.
Coi - The mandatory notification to the Texas State Board of Plumbing Examiners upon any changes to the policy safeguards against lapses in coverage.