Content Overview
The Texas Credentialing Application form, designated as LHL234 and revised in January 2007, is a crucial document for healthcare professionals seeking to establish their credentials with insurance carriers in Texas. This form, issued by the Texas Department of Insurance, captures a comprehensive range of personal and professional information. It begins with individual details, including the applicant's name, contact information, and social security number, followed by inquiries about citizenship and work eligibility. The education section requires specifics about professional degrees, postgraduate training, and any additional certifications. Applicants must also provide a detailed account of their licenses and certifications, including DEA and Medicaid provider numbers. The form further explores professional specialties, work history, and hospital affiliations, ensuring that all gaps in employment are explained. Additionally, references from peers in the same field are required, along with details about professional liability insurance coverage. Each section is meticulously designed to gather necessary information that supports the credentialing process, making it essential for healthcare providers aiming to practice effectively within the state.
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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 YEARS ASSOCIATED (YYYY-YYYY)
HOME MAILING ADDRESS
CITY STATE/COUNTRY POSTAL CODE
HOME PHONE NUMBER SOCIAL SECURITY NUMBER
Female Male
CORRESPONDENCE ADDRESS
CITY STATE/COUNTRY POSTAL CODE
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
Ye s No
DATES OF SERVICE (MM/DD/YYYY) TO
(MM/D /YYYY) D
LAST LOCATION
BRANCH OF SERVICE ARE YOU CURRENTLY ON ACTIVE OR RESERVE MILITARY DUTY?
Yes No
Education
PROFESSIONAL DEGREE (MEDICAL, DENTAL, CHIROPRACTIC, ETC.)
Issuing Institution:
ADDRESS
CIT Y STATE/COUNTRY POSTAL CODE
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
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Program successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR CURRENT PROGRAM DIRECTOR (IF KNOWN)
POST-GRADUATE EDUCATION SPECIALTY
Internship Residency Fellowship Teaching Appointment
INSTITUTION
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
1 of 20
Education
- continued
POST-GRADUATE EDUCATION
P
rogram successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR CURRENT PROGRAM DIRECTOR (IF KNOWN)
Please check this box and complete and submit Attachment B if you received additional postgraduate training.
OTHER GRADUATE-LEVEL EDUCATION
Issuing Institution:
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
DEGREE ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
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?
Y
es No
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?
Y
es No
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?
Y
es No
DEA Number:
ORIGINAL DATE OF ISSUE (MM/DD/YYYY) EXPIRATION DATE (MM/DD/YYYY)
DPS Number:
ORIGINAL DATE OF ISSUE (MM/DD/YYYY) EXPIRATION DATE (MM/DD/YYYY)
OTHER CDS (
PLEASE SPECIFY) NUMBER STATE OF REGISTRATION
ORIGINAL DATE OF ISSUE (MM/DD/YYYY) EXPIRATION DATE (MM/DD/YYYY) DO YOU CURRENTLY PRACTICE IN THIS STATE?
Y
es No
UPIN NATIONAL PROVIDER IDENTIFIER (WHEN AVAILABLE)
ARE YOU A PARTICIPATING MEDICARE PROVIDER?
Y
es No Medicare Provider Number:
ARE YOU A PARTICIPATING MEDICAID PROVIDER?
Yes No Medicaid Provider Number:
EDUCATIONAL COUNCIL FOR FOREIGN MEDICAL GRADUATES (ECFMG)
N
/A Yes No ECFMG Number:
ECFMG ISSUE DATE (MM/DD/YYYY)
Professional/Specialty Information
PRIMARY SPECIALTY BOARD CERTIFIED?
Yes No 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?
H
MO: Yes No PPO: Yes No POS: Yes No
SECONDARY SPECIALTY BOARD CERTIFIED?
Y
es No Name of Certifying Board:
INITIAL CERTIFICATION DATE (MM/YYYY) RECERTIFICATION DATE(S), IF APPLICABLE (MM/YYYY) EXPIRATION DATE, IF APPLICABLE (MM/YYYY)
2 of 20
Professional/Specialty Information
-continued
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?
H
MO: Yes No PPO: sYe No PO :S Yes No
ADDITIONAL SPECIALTY BOARD CERTIFIED?
Y
es No 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 tak n exam e , 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?
H
MO: Yes No PPO: Yes No POS: Yes No
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)
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PLEASE PROVIDE AN EXPLANATION FOR ANY GAPS GREATER THAN SIX MONTHS (MM/YYYY TO MM/YYYY) IN WORK HISTORY.
G
ap Dates:
Explanation:
Gap Dates:
Explanation:
3 of 20
Work History
– continued
Gap Dates: Exp
lanation:
Gap Dates: Exp
lanation:
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?
Y
es No
IF YOU DO NOT HAVE ADMITTING PRIVILEGES, WHAT ADMITTING ARRANGEMENTS DO YOU HAVE?
PRIMARY HOSPITAL WHERE YOU HAVE ADMITTING PRIVILEGES START DATE (MM/YYYY)
ADDRESS
CITY T
RY STATE/COUN POSTAL CODE
PHONE NUMBER FAX E-MAIL
FULL UNRESTRICTED PRIVILEGES?
Y
es No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.) ARE PRIVILEGES TEMPORARY?
Yes No
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 START DATE (MM/YYYY)
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
PHONE NUMBER FAX E-MAIL
FULL UNRESTRICTED PRIVILEGES?
Y
es
No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.) ARE PRIVILEGES TEMPORARY?
Yes No
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
M
M/YYYY)
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Y
es No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.) WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
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
PH
ONE NUMBER
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
4 of 20
References- continued
2 NAME/TITLE
PHONE NUMBER
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
3 NAME/TITLE
PHONE NUMBER
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
Professional Liability Insurance Coverage
SELF-INSURED?
Yes No
NAME OF CURRENT MALPRACTICE INSURANCE CARRIER OR SELF-INSURED ENTITY
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
PHONE NUMBER POLICY NUMBER EFFECTIVE DATE (MM/DD/YYYY) EXPIRATION DATE (MM/DD/YYYY)
AMOUNT OF COVERAGE PER
O
CCURRENCE
AMOUNT OF COVERAGE AGGREGATE TYPE OF COVERAGE
Individual Shared
LENGTH OF TIME WITH CARRIER
NAME OF PREVIOUS MALPRACTICE INSURANCE CARRIER IF WITH CURRENT CARRIER LESS THAN 5 YEARS
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
PHONE NUMBER POLICY NUMBER EFFECTIVE DATE (MM/DD/YYYY) EXPIRATION DATE (MM/DD/YYYY)
AMOUNT OF COVERAGE PER
O
CCURRENCE
AMOUNT OF COVERAGE AGGREGATE TYPE OF COVERAGE
Individual Shared
LENGTH OF TIME WITH CARRIER
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.
N
ame: Specialty:
Name: S
pecialty:
Name: S
pecialty:
Name: S
pecialty:
Name: S
pecialty:
PLEASE LIST FULL NAMES OF ALL PARTNERS IN YOUR PRACTICE. CHECK THIS BOX AND ATTACH LIST FOR LARGE GROUP.
N
ame: Name:
Name: N
ame:
Name: N
ame:
Name: N
ame:
5 of 20
Practice Location Information - Please answer the following questions for each practice location. Use Attachment F or
make copies of pages 6-7 as necessary.
PRACTICE LOCATION
of
TYPE OF SERV CE PROVIDEDI
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
P
rimary
CITY S
TATE/COUNTRY POSTAL CODE
PHONE NU
MBER FAX NUMBER E-MAIL
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?
Y
es No
IF NO, EXPECTED START DATE? (MM/DD/YYYY) DO YOU WANT THIS LOCATION LISTED IN THE
DIRECTORY? Yes No
OFFICE MANAGER OR STAFF CONTACT PHONE NUMBER FAX NUMBER
CREDENTIALING CONTACT
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
PHONE NUMBER FAX NUMBER E-MAIL
BILLING COMPANY'S NAME (
IF APPLICABLE) BILLING REPRESENTATIVE
ADDRESS
CITY S
TATE/COUNTRY POSTAL CODE
PHONE NUMBER FAX NUMBER E-MAIL
DEPARTMENT NAME IF HOSPITAL-BASED CHECK PAYABLE TO CAN YOU BILL ELECTRONICALLY?
Y
es No
HOURS PATIENTS ARE SEEN
M
onday No Office Hours Morning: Afternoon: Evening:
Tuesday No Office Hours Morning: Afternoon: Evening:
Wednesday No Office Hours Morning: Afternoon: Evening:
Thursday No Office Hours Morning: Afternoon: Evening:
Friday No Office Hours Morning: Afternoon: Evening:
Saturday No Office Hours Morning: Afternoon: Evening:
Sunday No Office Hours Morning: Afternoon: Evening:
DOES THIS LOCATION PROVIDE 24 HOUR/7 DAY A WEEK PHONE COVERAGE?
A
nswering Service Voice mail with instructions to call answering service Voice mail with other instructions None
THIS PRACTICE LOCATION ACCEPTS
a
ll 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.
PRACT
ICE L MI ITATIONS
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
L
OCATION?
Yes No If yes, provide the following information for each staff member:
NAME P
ROFESSIONAL DESIGNATION STATE & LICENSE NO.
NAME P
ROFESSIONAL DESIGNATION STATE & LICENSE NO.
6 of 20
Practice Location Information - continued
NAME P
ROFESSIONAL DESIGNATION STATE & LICENSE NO.
NAME P
ROFESSIONAL DESIGNATION STATE & LICENSE NO.
NAME P
ROFESSIONAL DESIGNATION STATE & LICENSE NO.
NAME P
ROFESSIONAL DESIGNATION STATE & LICENSE NO.
NON-ENGLISH LANGUAGES SPOKEN BY HEALTH CARE PROVIDERS NON-ENGLISH LANGUAGES SPOKEN BY OFFICE PERSONNEL
ARE INTERPRETERS AVAILABLE?
Y
es No If yes, please specify languages:
DOES THIS PRACTICE LOCATION MEET ADA ACCESSIBILITY STANDARDS?
Y
es No
WHICH OF THE FOLLOWING FACILITIES ARE HANDICAPPED ACCESSIBLE?
Building Parking Restroom Other:
DOES THIS LOCATION HAVE OTHER SERVICES FOR THE DISABLED?
T
ext Telephony-TTY American Sign Language-ASL Mental/Physical Impairment Services 0ther:
IS THIS LOCATION ACCESSIBLE BY PUBLIC TRANSPORTATION?
B
us Regional Train Other:
DOES THIS LOCATION PROVIDE CHILDCARE SERVICES?
Y
es No
DOES THIS LOCATION QUALIFY AS A MINORITY BUSINESS ENTERPRISE?
Yes No
WHO AT THIS LOCATION HAVE THE FOLLOWING CURRENT CERTIFICATIONS? (PLEASE LIST ONLY THE APPLICANT'S CERTIFICATION EXPIRATION DATES.)
B
asic Life Support Staff Provider Ex p: Advanced Life Support in OB Staff Provider Exp:
Advanced Trauma Life Support Staff Provider Exp: Cardio-Pulmonary Resuscitation Staff Provider Exp:
Advanced Cardiac Life Support Staff Provider Exp: Pediatric Advanced Life Support Staff Provider Exp:
Neonatal Advanced Life Support Staff iProv der Exp: Other (please specify) Staff Provider Exp:
DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? Yes No
L
aboratory Services; please list all Certificates of Participation (CLIA, AAFP, COLA, CAP, MLE):
DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? Yes No
X
-ray; please list all certifications:
OTHER SERVICES
Ra
diology 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
Other:
PLEASE LIST ANY ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)
IS ANESTHESIA ADMINISTERED AT THIS PRACTICE LOCATION?
Y
es No Please specify the classes or categories:
WHO ADMINISTERS IT?
Please c
heck this box and complete and submit Attachment F if you have other practice locations.
7 of 20
Section II-Disclosure Questions - Please provide an explanation for any question answered yes-except 16-on
page 10.
Licensure
1 H
as 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?
Yes No
2 H
ave you ever received a reprimand or been fined by any state licensing board?
Yes No
Hospital Privileges and Other Affiliations
3 H
ave 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?
Yes No
4 H
ave you voluntarily surrendered, limited your privileges or not reapplied for privileges while under
investigation?
Yes No
5 H
ave 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)?
Yes No
Education, Training and Board Certification
6 W
ere 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?
Yes No
7 H
ave 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?
Yes No
8 H
ave any of your board certifications or eligibility ever been revoked?
Yes No
9 H
ave you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while
under investigation?
Yes No
DEA or DPS
10 H
ave your Federal DEA and/or DPS Controlled Substances Certificate(s) or authorization(s) ever been
denied, suspended, revoked, restricted, denied renewal, or voluntarily relinquished?
Yes No
Medicare, Medicaid or other Governmental Program Participation
11 H
ave 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?
Yes No
Other Sanctions or Investigations
12 A
re 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?
Yes No
8 of 20
Section II - Disclosure Questions -
continued
Other Sanctions or Investigations
13 To your knowledge, has information pertaining to you ever been reported to the National Practitioner
Data Bank or Healthcare Integrity and Protection Data Bank?
Yes No
14 Have you ever received sanctions from or been the subject of investigation by any regulatory
a
gencies (e.g., CLIA, OSHA, etc.)?
Yes No
15 Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital,
f
acility, or agency, or voluntarily terminated or resigned while under investigation by a hospital or
healthcare facility of any military agency?
Yes No
Malpractice Claims History
16 H
ave you had any malpractice
mediated or litigated?
actions within the past 5 years (pending, settled, arbitrated,
Yes No
If yes, please check this box and complete and submit Attachment G.
Criminal
17
Have 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?
Yes
No
18
Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony including a n
act of violence, child abuse or a sexual offense?
Yes
No
19
Have you been court-martialed for actions related to your duties as a medical professional?
Yes
No
Ability to Perform Job
20 Are 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.)
Yes No
21 Do 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?
Yes No
Ability to Perform Job
22 Do you have any reason to believe that you would pose a risk to the safety or well-being of your
patients?
Yes No
23 Are you unable to perform the essential functions of a practitioner in your area of practice, with or
without reasonable accommodation?
Yes No
Please use the space on page 10 to explain yes answers to any question except #16.
9 of 20
Section II - Disclosure Questions
-continued
Please use the space below to explain yes answers to any question except 16.
QUESTION NUMBER PLEASE EXPLAIN
10 of 20
Form Specifications
| Fact Name | Details |
|---|---|
| Form Title | Texas Standardized Credentialing Application |
| Governing Law | Promulgated pursuant to Texas Insurance Code § 1452.052 |
| Issuing Authority | Texas Department of Insurance |
| Submission Requirement | Must be sent to the carrier for credentialing |
| Revision Date | LHL234 Rev. 01/07 |
Texas Credentialing Application: Usage Guidelines
Completing the Texas Credentialing Application form is an important step in your professional journey. Ensure that all information is accurate and up-to-date. After submitting your application, the next steps will involve verification by the carrier you choose to work with. This process can take some time, so it’s essential to be thorough and prompt in your submission.
- Begin by filling out Section I with your individual information. Include your full name, maiden name, and any other names you've used.
- Provide your home mailing address, phone number, and email address. Make sure to include your date and place of birth, as well as your citizenship status.
- Indicate your eligibility to work in the United States and provide details about your military service, if applicable.
- Complete the Education section by listing your professional degree, the institution that issued it, and your attendance dates.
- If you have additional degrees, check the appropriate box and attach the necessary documentation.
- Fill out the Licenses and Certificates section. Include all licenses and certifications, along with their details, such as license type, number, and expiration dates.
- Provide your National Provider Identifier (NPI) and indicate if you are a participating Medicare or Medicaid provider.
- In the Professional/Specialty Information section, specify your primary specialty and whether you are board certified. Include details about any additional specialties as well.
- List your work history chronologically, providing the names and addresses of your current and previous employers, along with the dates of employment.
- Document any gaps in your work history that exceed six months and provide explanations for each gap.
- In the Hospital Affiliations section, indicate whether you have hospital privileges and provide details about the hospitals where you have privileges.
- List three peer references who can speak to your professional abilities. Ensure they are not partners or relatives.
- Complete the Professional Liability Insurance Coverage section, detailing your current and previous malpractice insurance coverage.
- List any colleagues providing regular call coverage and the names of all partners in your practice.
- Review the entire application for accuracy before submission. Attach any necessary documents as specified in the form.
Your Questions, Answered
What is the Texas Credentialing Application form?
The Texas Credentialing Application form is a standardized document required by the Texas Department of Insurance for healthcare professionals seeking credentialing with insurance carriers. It collects essential information about the applicant's professional background, education, licenses, work history, and specialties. This application must be submitted to the insurance carrier with which the individual wishes to become credentialed.
Who needs to complete the Texas Credentialing Application?
Healthcare professionals, including physicians, dentists, and other licensed practitioners, must complete this application if they intend to become credentialed by an insurance carrier in Texas. This includes those who are newly entering the workforce as well as those who are changing their practice locations or insurance affiliations.
What information is required on the application?
The application requires personal details such as the applicant's name, contact information, date of birth, and Social Security number. Additionally, it asks for educational background, including degrees and postgraduate training, licenses and certifications, work history, hospital affiliations, references, and professional liability insurance information. Each section must be filled out accurately to ensure a smooth credentialing process.
How should I submit the application?
Once completed, the Texas Credentialing Application form should be sent directly to the insurance carrier with whom the applicant wishes to become credentialed. It is important to check the specific submission guidelines of the carrier, as they may have different requirements regarding electronic or paper submissions.
What if I have gaps in my work history?
If there are gaps in your work history that exceed six months, the application requires an explanation for each gap. Providing clear and honest explanations can help prevent delays in the credentialing process. It is advisable to prepare this information in advance to ensure completeness of the application.
Can I submit additional information with my application?
Yes, applicants can submit additional information to support their application. This includes a Curriculum Vitae (CV) for a more detailed work history, or attachments for any additional postgraduate training or work history. It is crucial to label these attachments clearly and ensure they are relevant to the application.
How long does the credentialing process take?
The length of the credentialing process can vary significantly based on the insurance carrier and the completeness of the submitted application. Generally, it can take anywhere from a few weeks to several months. Applicants are encouraged to follow up with the carrier to check on the status of their application and provide any additional information if requested.
Common mistakes
-
Incomplete Personal Information: Many applicants forget to fill in all required personal details, such as their social security number or date of birth. Missing this information can delay the processing of the application.
-
Incorrect License Information: It's common for individuals to misreport their license type or license number. Double-checking this information is crucial, as discrepancies can lead to rejections or delays.
-
Omitting Work History: Some applicants fail to provide a complete chronological work history. Gaps in employment lasting more than six months must be explained. Neglecting to do so can raise red flags during the review process.
-
Ignoring Required Attachments: The application may require additional documents, such as Attachment A or Attachment B. Failing to include these can result in an incomplete application, causing further delays.
Documents used along the form
The Texas Credentialing Application form is a crucial document for healthcare professionals seeking to be credentialed by insurance carriers. Along with this application, several other forms and documents are typically required to complete the credentialing process. Each of these documents provides essential information that supports the application and verifies the applicant's qualifications.
- Curriculum Vitae (CV): A detailed overview of the applicant's education, work history, and professional achievements. It helps to present a comprehensive picture of the applicant's qualifications.
- Professional Licenses: Copies of all active licenses held by the applicant in various states. This confirms the legal authority to practice in those jurisdictions.
- Board Certification Documentation: Proof of board certification in the applicant's specialty. This document demonstrates the applicant's expertise and commitment to their field.
- Malpractice Insurance Certificate: A document showing current malpractice insurance coverage. This protects both the practitioner and the patients they serve.
- Peer References: Letters or forms from professional peers who can attest to the applicant's skills and character. These references provide credibility to the application.
- Hospital Privileges Documentation: Information regarding current or past hospital privileges. This helps to establish the applicant's involvement in the healthcare community.
- Background Check Authorization: A form allowing the credentialing body to conduct a background check. This ensures the applicant meets the necessary ethical and legal standards.
Gathering these documents is essential for a smooth credentialing process. Each piece of information plays a vital role in verifying the applicant's qualifications and ensuring they meet the standards required by insurance carriers and healthcare institutions.
Similar forms
- Credentialing Application for Medical Staff: This document is used by hospitals to assess the qualifications of healthcare providers. Similar to the Texas Credentialing Application, it collects personal information, education history, and professional experience to ensure that applicants meet the necessary standards for practice.
- National Practitioner Data Bank (NPDB) Report: This report provides information about a healthcare provider's licensure, malpractice history, and any disciplinary actions. Like the Texas Credentialing Application, it helps organizations verify the credentials and background of medical professionals before granting privileges.
- State Medical Board Application: This application is required for obtaining a medical license in a specific state. It includes personal details, education, training, and work history, paralleling the Texas Credentialing Application in its goal to ensure that practitioners are qualified to provide care.
- Medicare Enrollment Application: This form is necessary for healthcare providers who want to bill Medicare for services. It gathers information about the provider's credentials, much like the Texas Credentialing Application, to confirm eligibility for participation in the Medicare program.
- Malpractice Insurance Application: This document is used to apply for malpractice insurance coverage. It requests similar information regarding professional history and qualifications, ensuring that the provider meets the insurer's criteria, akin to the requirements found in the Texas Credentialing Application.
Dos and Don'ts
When filling out the Texas Credentialing Application form, it's essential to follow certain guidelines to ensure a smooth process. Below is a list of things to do and avoid.
- Do read the entire application carefully before starting.
- Do provide accurate and complete information for each section.
- Do double-check all dates, especially those related to education and work history.
- Do keep a copy of the completed application for your records.
- Do submit any required attachments, such as additional work history or references.
- Don't leave any sections blank; if a section does not apply, indicate that clearly.
- Don't rush through the application; take your time to ensure accuracy.
- Don't provide misleading or false information, as this can lead to disqualification.
- Don't forget to include your contact information and be available for follow-up questions.
Misconceptions
- Misconception 1: The Texas Credentialing Application is only for new applicants.
- Misconception 2: The application does not require detailed work history.
- Misconception 3: All licenses and certifications must be from Texas.
- Misconception 4: Only medical professionals need to fill out this application.
- Misconception 5: There is no need to provide references.
- Misconception 6: The application process is quick and straightforward.
This form is required for both new applicants and those seeking to update their credentials. It serves as a comprehensive record of a professional's qualifications, regardless of their experience level.
In fact, the application mandates a chronological work history, including explanations for any employment gaps exceeding six months. This information is critical for a thorough review of the applicant's background.
Applicants must include all licenses and certifications from any state where they have been licensed. This ensures that the credentialing process considers the applicant's complete professional history.
The application is applicable to various types of healthcare professionals, including dental and chiropractic practitioners. It is not limited to one specific field.
The application explicitly requires three peer references from the same field or specialty. These references must not be relatives or partners in the applicant's practice, ensuring an unbiased assessment of qualifications.
While the application form may seem simple, gathering all necessary documentation and completing it thoroughly can be time-consuming. Applicants should allow adequate time for this process to avoid delays in credentialing.
Key takeaways
Understand the Purpose: The Texas Credentialing Application is designed to help you become credentialed with a specific insurance carrier. Completing this form is a crucial step in establishing your professional practice.
Gather Personal Information: Before starting the application, collect all necessary personal details, including your full name, date of birth, and Social Security number. This information is essential for identification purposes.
Document Your Education: Be prepared to provide comprehensive details about your educational background, including professional degrees and postgraduate training. Include the names of institutions, attendance dates, and any relevant certifications.
List All Licenses: Ensure that you include every license and certification you hold, along with their respective details such as license numbers, states of registration, and expiration dates. This information is vital for your credentialing process.
Detail Your Work History: A chronological account of your work history is required. Include all relevant positions held, along with start and end dates. If there are gaps in your employment, be prepared to explain them clearly.
Provide Hospital Affiliations: If you have admitting privileges at any hospitals, list them along with the types of privileges you hold. This information is necessary for assessing your capabilities within a hospital setting.
Include Peer References: You will need to provide three peer references from professionals in your field. Choose individuals who can speak to your qualifications and experience, and ensure they are not related to you or partners in your practice.
Insurance Information: Be ready to share details about your malpractice insurance coverage. This includes the name of your insurance carrier, policy number, and coverage amounts. This information helps assess your professional liability.
Review and Submit: After completing the application, carefully review all entries for accuracy and completeness. Submit the application to the appropriate insurance carrier promptly to avoid delays in your credentialing process.