Fillable Texas Standardized Credentialing Application (Please type or print) (Texas Real Estate Contracts)

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Texas Standardized Credentialing Application (Please type or print) (Texas Real Estate Contracts)

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The Texas Real Estate Commission (TREC) is an agency that governs real estate practices in the state of Texas USA. I its headquarters are located in Ausin Texas at 1700 North Congress.

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LHL234 Rev.01/07 1 of 20
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
DATES OF SERVICE
(MM/DD/YYYY) TO
LAST LOCATION
Ye
(MM/D /YYYY)
s
No
D
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 STATE/COUNTRY POSTAL CODE
Y
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
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
Program successfully completed
PROGRAM DIRECTOR CURRENT PROGRAM DIRECTOR (IF KNOWN)
POST-GRADUATE EDUCATION
SPECIALTY
Internship
Residency
Fellowship
Teaching Appointment
INSTITUTION
DDRESS
A
CITY
STATE/COUNTRY POSTAL CODE
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.
Texas Standardized Credentialing Application (Please type or print)
Education
- continued
POST-GRADUATE EDUCATION ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
Program successfully completed
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 STATE/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?
Yes 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?
Yes
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?
Yes
No
ORIGINAL DATE OF ISSUE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
DEA
Number:
ORIGINAL DATE OF ISSUE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
DPS
Number:
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?
Yes
No
UPIN
NATIONAL PROVIDER IDENTIFIER (WHEN AVAILABLE)
ARE YOU A PARTICIPATING
MEDICARE PROVIDER?
ARE YOU A PARTICIPATING
MEDICAID PROVIDER?
Yes
No
Medicare Provider Number:
Yes
No
Medicaid Provider Number:
EDUCATIONAL COUNCIL FOR FOREIGN MEDICAL GRADUATES (ECFMG)
ECFMG ISSUE DATE (MM/DD/YYYY)
N/A Yes No ECFMG Number:
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?
HMO: Yes
No
PPO: Yes
No
POS:
Yes
No
SECONDARY 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)
LHL234 Rev.01/07 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?
HMO:
Yes
No
PPO: s
No
PO :
Ye S Yes
No
ADDITIONAL 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.
have tak n exam I 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?
HMO:
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 Cu rriculum 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)
ESS
ADDR
CITY
STATE/COUN TRY POSTAL CODE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUN TRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUN TRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUN TRY POSTAL CODE
REASON FOR DISCONTINUANCE
PLEASE PROVIDE AN EXPLANATION FOR ANY GAPS GREATER THAN SIX MONTHS (MM/YY YY TO MM/YYYY) IN WORK HISTORY.
Gap Dates:
Explanation:
Gap Dates:
Explanation:
LHL234 Rev.01/07 3 of 20
Work History
– continued
Gap Dates:
LHL234 Rev.01/07 4 of 20
Explanation:
Gap Dates:
Explanation:
Please check this box and complete and submit Attachment C if you have additional work history
Hospital Affiliations-Please include all hospitals w here 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?
Yes No
PRIMARY HOSPITAL
WHERE YOU HAVE ADMITTING PRIVILEGES
START DATE (MM/YYYY)
ADDRESS
CITY
TRY POSTAL CODE
STATE/COUN
PHONE NUMBER FAX E-MAIL
FULL UNRESTRICTED PRIVILEGES? TYPES
OF
PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL,
ETC.)
ARE PRIVILEGES TEMPORARY?
Yes
No
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
STATE/COUNTRY POSTAL CODE
PHONE NUMBER FAX E-MAIL
FULL UNRESTRICTED PRIVILEGES? TYPES
OF
PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL,
ETC.)
ARE PRIVILEGES TEMPORARY?
Yes
No 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
MM/YYYY)
ADDRESS
CITY
STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES? TYPES
OF
PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL,
ETC.)
WERE PRIVILEGES TEMPORARY?
Yes
No
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
PHONE NUMBER
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
References- continued
2 NAME/TITLE
PHONE NUMBER
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
3 NAME/TITLE
PHONE NUMBER
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Professional Liability Insurance Coverage
SELF-INSURED? NAME OF CURRENT MALPRACTICE INSURANCE CARRIER OR SELF-INSURED ENTITY
Yes No
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER POLICY NUMBER EFFECTIVE DATE (MM/DD/YYYY) EXPIRATION 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
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER POLICY NUMBER EFFECTIVE DATE (MM/DD/YYYY) EXPIRATION DATE (MM/DD/YYYY)
AMOUNT OF COVERAGE PER AMOUNT OF COVERAGE AGGREGATE TYPE OF COVERAGE LENGTH OF TIME WITH CARRIER
OCCURRENCE
Individual Shared
Call Coverage
See attached list of hospital staff within my department I utilize for call coverage.
PLEASE LIST NAMES OF COLLEAGUE(S) PROV IDING REGULAR COVERAGE AND HIS OR HER SPECIALTIES.
Name:
Specialty:
Name:
Specialty:
Name:
Specialty:
Name:
Specialty:
Name:
Specialty:
PLEASE LIST FULL NAMES OF ALL PARTNERS IN YOUR PRACTICE. CHECK THIS BOX AND ATTACH LIST FOR LARGE GROUP.
Name:
Name:
Name:
Name:
Name:
Name:
Name:
Name:
LHL234 Rev.01/07 5 of 20
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 SERV CE PROVIDED
I
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
CITY
STATE/COUNTRY POSTAL CODE
UMBER
PHONE N 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?
IF NO, EXPECTED
START DATE? (MM/DD/YYYY)
DO YOU
WANT THIS LOCATION LISTED IN THE
Yes No
DIRECTORY?
Yes No
OFFICE MANAGER OR STAFF CONTACT PHONE NUMBER FAX NUMBER
CREDENTIALING CONTACT
ADDRESS
CITY
STATE/COUNTRY POSTAL CODE
PHONE NUMBER FAX NUMBER E-MAIL
BILLING COMPANY'S NAME (IF APPLICABLE) BILLING REPRESENTATIVE
ADDRESS
CITY
STATE/COUNTRY POSTAL CODE
PHONE NUMBER FAX NUMBER E-MAIL
DEPARTMENT NAME IF HOSPITAL-BASED
CHECK PAYABLE TO CAN YOU BILL ELECTRONICALLY?
Yes No
HOURS PATIENTS ARE SEEN
Monday No Office Hours Morning:
Afterno :
on
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?
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.
TICE L M
PRAC I 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
LOCATION?
Yes No
If yes, provide the following
information for each staff member:
NAME
PROFESSIONAL DESIGNATION STATE & LICENSE NO.
NAME
PROFESSIONAL DESIGNATION STATE & LICENSE NO.
LHL234 Rev.01/07 6 of 20
Practice Location Information - continued
NAME PROFESSIONAL DESIGNATION STATE & LICENSE NO.
NAME PROFESSIONAL DESIGNATION STATE & LICENSE NO.
NAME PROFESSIONAL DESIGNATION STATE & LICENSE NO.
NAME PROFESSIONAL DESIGNATION STATE & LICENSE NO.
NON-ENGLISH LANGUAGES SPOKEN BY HEALTH CARE PROVIDERS NON-ENGLISH LANGUAGES SPOKEN BY OFFICE PERSONNEL
ARE INTERPRETERS AVAILABLE?
Yes
No
If yes, please specify
languages:
DOES THIS PRACTICE LOCATION
MEET ADA ACCESSIBILITY STANDARDS?
WHICH OF THE FOLLOWING FACILITIES ARE HANDICAPPED ACCESSIBLE?
Yes
No Building Parking Restroom
Other:
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 Other:
DOES THIS LOCATION PROVIDE CHILDCARE SERVICES?
DOES THIS LOCATION QUALIFY AS
A MINORITY BUSINESS ENTERPRISE?
Yes
No
Yes
No
WHO AT THIS LOCATION HAVE THE FOLLOWING CURRENT CERTIFICATIONS? (PLEASE LIST ONLY THE APPLICANT'S CERTIFICATION EXPIRATION DATES.)
Basic Life Support Provider Ex
Staff 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
i
Staff Provder Exp:
Other (please specify)
Staff Provider Exp:
DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE?
Yes
No
Laboratory 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
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
Other:
PLEASE LIST ANY ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)
IS ANESTHESIA ADMINISTERED AT THIS
PRACTICE LOCATION? WHO ADMINISTERS IT?
Yes
No Please specify the classes or categories:
Please
check this box and complete
and submit Attachment F if you have other practice locations.
LHL234 Rev.01/07 7 of 20
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes No
Yes
Yes
Section II-Disclosure Questions - Please provide an explanation for any question answered yes-except 16-on
page 10.
Licensure
1 Has 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?
No
2 Have you ever received a reprimand or been fined by any state licensing board?
No
Hospital Privileges and Other Affiliations
3 Have 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?
No
4 Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while under
investigation?
No
5 Have 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)?
No
Education, Training and Board Certification
6 Were you ever placed on probation, disciplined, formally reprimanded, suspended or aske d to resign
during an internship, residency, fellowship, preceptorship or other clinical education progr am? If you
are currently in a training program, have you been placed on probation, discipline d, formally
reprimanded, suspended or asked to resign?
No
7 Have 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 cl inical
education program?
No
8 Have any of your board certifications or eligibility ever been revoked?
No
9 Have you ever chosen not to re-certify or voluntarily surrendered your board certificat ion(s) while
under investigation?
No
DEA or DPS
10 Have your Federal DEA and/or DPS Controlled Substances Certificate(s) or authorization(s) ever been
denied, suspended, revoked, restricted, denied renewal, or voluntarily relinquished?
No
Medicare, Medicaid or other Governmental Program Participation
11 Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, s anctioned,
censured, disqualified or otherwise restricted in regard to participation in the Medicare o r Medicaid
program, or in regard to other federal or state governmental health care plans or program s?
Other Sanctions or Investigations
12 Are you currently or have you ever been the subject of an investigation by any hospita l, licensing
authority, DEA or DPS authorizing entities, education or training program, Medicare o r Medicaid
program, or any other private, federal or state health program?
No
LHL234 Rev.01/07 8 of 20
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Section II - Disclosure Questions -
continued
No
14 Have you ever received sanctions from or been the subject of investigation by any regulator y
agencies (e.g., CLIA, OSHA, etc.)?
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?
No
15 Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospita l,
facility, or agency, or voluntarily terminated or resigned while under investigation by a hospital o r
healthcare facility of any military agency?
No
Malpractice Claims History
16 Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated ,
mediated or litigated?
No
If yes, please check this box and complete and submit Attachment G.
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?
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
No
19 Have you been court-martialed for actions related to your duties as a medical professional?
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 pr actic e
medicine. It is not limited to the day of, or within a matter of days or weeks before the d ate o f
application, rather that it has occurred recently enough to indicate the individual is actively en gage d
in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful unde r
the Controlled Substances Act, 21 U.S.C. § 812.22. It "does not include the use of a drug taken unde r
supervision by a licensed health care professional, or other uses authorized by the Con trolled
Substances Act or other provision of Federal law." The term does include, however, the unlawful use o f
prescription controlled substances.)
No
21 Do you use any chemical substances that would in any way impair or limit your ability to practic e
medicine and perform the functions of your job with reasonable skill and safety?
No
No
23 Are you unable to perform the essential functions of a practitioner in your area of practice, with or
without reasonable accommodation?
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 you r
patients?
No
Please use the space on page 10 to explain yes answers to any question except #16.
LHL234 Rev.01/07 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
LHL234 Rev.01/07 10 of 20
Section III – Standard Authorization, Attestation and Release (Not for Use for Employment Purposes)
I understand and agree that, as part of the credentialing application process for participation and⁄or clinical privileges
(hereinafter, referred to as “Participation”) at or with
(PLEASE INDICATE MANAGED CARE COMPANY(S) OR HOSPITAL(S) TO WHICH YOU ARE APPLYING) (HEREINAFTER, INDIVIDUALLY REFERRED TO AS THE “ENTITY”)
and any of the Entity’s affiliated entities, I am required to provide sufficient and accurate information for a proper evaluation
of my current licensure, relevant training and⁄or experience, clinical competence, health status, character, ethics, and any
other criteria used by the Entity for determining initial and ongoing eligibility for Participation. Each Entity and its
representatives, employees, and agent(s) acknowledge that the information obtained relating to the application process will
be held confidential to the extent permitted by law.
I acknowledge that each Entity has its own criteria for acceptance, and I may be accepted or rejected by each
independently. I further acknowledge and understand that my cooperation in obtaining information and my consent to the
release of information do not guarantee that any Entity will grant me clinical privileges or contract with me as a provider of
services. I understand that my application for Participation with the Entity is not an application for employment with the Entity
and that acceptance of my application by the Entity will not result in my employment by the Entity.
For Hospital Credentialing. I consent to appear for an interview with the credentials committee, medical staff executive
committee, or other representatives of the medical staff, hospital administration or the governing board, if required or
requested. As a medical staff member, I pledge to provide continuous care for my patients. I have been informed of existing
hospital bylaws, rules and regulations, and policies regarding the application process, and I agree that as a medical staff
member, I will be bound by them.
Authorization of Investigation Concerning Application for Participation. I authorize the following individuals including, without
limitation, the Entity, its representatives, employees, and/or designated agent(s); the Entity’s affiliated entities and their
representatives, employees, and/or designated agents; and the Entity’s designated professional credentials verification
organization (collectively referred to as “Agents”), to investigate information, which includes both oral and written statements,
records, and documents, concerning my application for Participation. I agree to allow the Entity and/or its Agent(s) to inspect
all records and documents relating to such an investigation.
Authorization of Third-Party Sources to Release Information Concerning Application for Participation. I authorize any third party,
including, but not limited to, individuals, agencies, medical groups responsible for credentials verification, corporations,
companies, employers, former employers, hospitals, health plans, health maintenance organizations, managed care
organizations, law enforcement or licensing agencies, insurance companies, educational and other institutions, military
services, medical credentialing and accreditation agencies, professional medical societies, the Federation of State Medical
Boards, the National Practitioner Data Bank, and the Health Care Integrity and Protection Data Bank, to release to the Entity
and/or its Agent(s), information, including otherwise privileged or confidential information, concerning my professional
qualifications, credentials, clinical competence, quality assurance and utilization data, character, mental condition, physical
condition, alcohol or chemical dependency diagnosis and treatment, ethics, behavior, or any other matter reasonably having
a bearing on my qualifications for Participation in, or with, the Entity. I authorize my current and past professional liability
carrier(s) to release my history of claims that have been made and/or are currently pending against me. I specifically waive
written notice from any entities and individuals who provide information based upon this Authorization, Attestation and
Release.
Authorization of Release and Exchange of Disciplinary Information. I hereby further authorize any third party at which I currently
have Participation or had Participation and/or each third party’s agents to release “Disciplinary Information,” as defined
below, to the Entity and/or its Agent(s). I hereby further authorize the Agent(s) to release Disciplinary Information about any
disciplinary action taken against me to its participating Entities at which I have Participation, and as may be otherwise
required by law. As used herein, “Disciplinary Information” means information concerning: (I) any action taken by such health
care organizations, their administrators, or their medical or other committees to revoke, deny, suspend, restrict, or condition my
Participation or impose a corrective action plan; (ii) any other disciplinary action involving me, including, but not limited to,
discipline in the employment context; or (iii) my resignation prior to the conclusion of any disciplinary proceedings or prior to
the commencement of formal charges, but after I have knowledge that such formal charges were being (or are being)
contemplated and/or were (or are) in preparation.
Release from Liability. I release from all liability and hold harmless any Entity, its Agent(s), and any other third party for their acts
performed in good faith and without malice unless such acts are due to the gross negligence or willful misconduct of the
Entity, its Agent(s), or other third party in connection with the gathering, release and exchange of, and reliance upon,
information used in accordance with this Authorization, Attestation and Release. I further agree not to sue any Entity, any
Agent(s), or any other third
APPLICANT’S INITIALS AND DATE (MM⁄DD⁄YYYY)
LHL234 Rev.01/07 11 of 20
NAME (PLEASE PRINT OR TYPE)
Last 4 digits of SSN or NPI (PLEASE PRINT OR TYPE)
DATE (MM⁄DD⁄YYYY)
Copy of DEA or state DPS Controlled Substances Registration Certificate
Copy of other Controlled Dangerous Substances Registration Certificate(s)
Copy of current professional liability insurance policy face sheet, showing expiration dates, limits and applicant’s name
Copies of IRS W-9s for verification of each tax identification number used
Copy of workers compensation certificate of coverage, if applicable
Copy of CLIA certifications, if applicable
Copies of radiology certifications, if applicable
Copy of DD214, record of military service, if applicable
Section III – Standard Authorization, Attestation and Release –continued
party for their acts, defamation or any other claims based on statements made in good faith and without malice or
misconduct of such Entity, Agent(s) or third party in connection with the credentialing process. This release shall be in addition
to, and in no way shall limit, any other applicable immunities provided by law for peer review and credentialing activities.
In this Authorization, Attestation and Release, all references to the Entity, its Agent(s), and⁄or other third party include their
respective employees, directors, officers, advisors, counsel, and agents. The Entity or any of its affiliates or agents retains the
right to allow access to the application information for purposes of a credentialing audit to customers and⁄or their auditors to
the extent required in connection with an audit of the credentialing processes and provided that the customer and⁄or their
auditor executes an appropriate confidentiality agreement. I understand and agree that this Authorization, Attestation and
Release is irrevocable for any period during which I am an applicant for Participation at an Entity, a member of an Entity’s
medical or health care staff, or a participating provider of an Entity. I agree to execute another form of consent if law or
regulation limits the application of this irrevocable authorization. I understand that my failure to promptly provide another
consent may be grounds for termination or discipline by the Entity in accordance with the applicable bylaws, rules, and
regulations, and requirements of the Entity, or grounds for my termination of Participation at or with the Entity. I agree that
information obtained in accordance with the provisions of this Authorization, Attestation and Release is not and will not be a
violation of my privacy.
I certify that all information provided by me in my application is true, correct, and complete to the best of my knowledge and
belief, and that I will notify the Entity and⁄or its Agent(s) within 10 days of any material changes to the information I have
provided in my application or authorized to be released pursuant to the credentialing process. I understand that corrections to
the application are permitted at any time prior to a determination of Participation by the Entity, and must be submitted on-line
or in writing, and must be dated and signed by me (may be a written or an electronic signature). I understand and agree that
any material misstatement or omission in the application may constitute grounds for withdrawal of the application from
consideration; denial or revocation of Participation; and⁄or immediate suspension or termination of Participation. This action
may be disclosed to the Entity and⁄or its Agent(s).
I further acknowledge that I have read and understand the foregoing Authorization, Attestation and Release. I understand
and agree that a facsimile or photocopy of this Authorization, Attestation and Release shall be as effective as the original.
SIGNATURE
Required Attachments or Supplemental Information – Please attach hard copy or scanned documents of the following:
LHL234 Rev.01/07 12 of 20
Reproduction of this form without any changes is allowed.
Notice About Certain Information Laws and Practices Pertaining to State Governmental Bodies (i.e. State Hospitals)
With few exceptions, you are entitled to be informed about the information that a state governmental body collects about
you (i.e. a state hospital). Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or
receive copies of information about yourself, including private information. However the state governmental body may
withhold information for reasons other than to protect your right to privacy. Under section 559.004 of the Texas Government
Code, you are entitled to request that the state governmental body correct information that it has about you that is incorrect.
For information about the procedure and costs for obtaining information, please contact the appropriate state governmental
body to which you have submitted this application.
LHL234 Rev.01/07 13 of 20
Texas Standardized Credentialing Application
Attachment A – Other Professional Degrees
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
OTHER PROFESSIONAL DEGREE
Issuing Institution:
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
DEGREE ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
Texas Standardized Credentialing Application
Attachment B – Other Post Graduate Education
OTHER POST-GRADUATE EDUCATION
Internship Residency Fellowship Teaching Appointment
SPECIALTY
INSTITUTION
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Program successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR CURRENT PROGRAM DIRECTOR (IF KNOWN)
OTHER POST-GRADUATE EDUCATION
Internship Residency Fellowship Teaching Appointment
SPECIALTY
INSTITUTION
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Program successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR CURRENT PROGRAM DIRECTOR (IF KNOWN)
OTHER POST-GRADUATE EDUCATION
Internship Residency Fellowship Teaching Appointment
SPECIALTY
INSTITUTION
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Program successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR CURRENT PROGRAM DIRECTOR (IF KNOWN)
OTHER POST-GRADUATE EDUCATION
Internship Residency Fellowship Teaching Appointment
SPECIALTY
INSTITUTION
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Program successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR CURRENT PROGRAM DIRECTOR (IF KNOWN)
OTHER POST-GRADUATE EDUCATION
Internship Residency Fellowship Teaching Appointment
SPECIALTY
INSTITUTION
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
Program successfully completed
ATTENDANCE DATES (MM/YYYY TO MM/YYYY)
PROGRAM DIRECTOR CURRENT PROGRAM DIRECTOR (IF KNOWN)
LHL234 Rev.01/07 14 of 20
LHL234 Rev.01/07 15 of 20
PREVIOUS PRACTICE/EMPLOYER NAME START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME START DATE/END
DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY
STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME START DATE/END
DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
REA ON FOR DIS
S CONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END
DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY
STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END
DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END
DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY
STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END
DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY
STATE/COUNTRY POSTAL CODE
REASON FOR DISCONTINUANCE
Texas Standardized Credentialing Application
Attachment C – Other Work History
OTHER HOSPITAL WHERE YOU HAVE PRIVILEGES START DATE (MM/YYYY)
A
LHL234 Rev.01/07 16 of 20
DDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER FAX MAIL
E-
FULL UNRESTRICTED PRIVILEGES? TYPES
OF
PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL,
ETC.)
ARE PRIVILEGES TEMPORARY?
Yes
No
Yes
No
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR,
WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?
OTHER HOSPITAL WHERE YOU HAVE
PRIVILEGES START DATE (MM/YYYY)
ADDRESS
CITY
STATE/COUNTRY POSTAL CODE
PHONE NUMBER FA MAIL
X E-
FULL UNRESTRICTED PRIVILEGES? TYPES
OF
PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL,
ETC.)
ARE PRIVILEGES TEMPORARY?
Yes
No
Yes
No
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR,
WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?
OTHER HOSPITAL WHERE YOU HAVE
PRIVILEGES START DATE (MM/YYYY)
ADDRESS
CITY
STATE/COUNTRY POSTAL CODE
PHONE NUMBER FAX E-MAIL
FULL UNRESTRICTED PRIVILEGES? TYPES
OF
PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL,
ETC.)
ARE PRIVILEGES TEMPORARY?
Yes
No
Yes
No
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR,
WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?
OTHER HOSPITAL WHERE YOU HAVE
PRIVILEGES START DATE (MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER FAX E-MAIL
FULL UNRESTRICTED PRIVILEGES? TYPES
OF
PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL,
ETC.)
ARE PRIVILEGES TEMPORARY?
Yes
No
Yes
No
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR,
WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?
OTHER HOSPITAL WHERE YOU HAVE
PRIVILEGES START DATE (MM/YYYY)
ADDRESS
CITY
STATE/COUNTRY POSTAL CODE
PHONE NUMB
ER FAX E-MAIL
FULL UNRESTRICTED PRIVILEGES? TYPES
OF
PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL,
ETC.)
ARE PRIVILEGES TEMPORARY?
Yes
No
Yes
No
OF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR,
WHAT PERCENTAGE IS TO THIS SPECIFIC HOSPITAL?
Texas Standardized Credentialing Application
Attachment D – Other Current Hospital Affiliations
LHL234 Rev.01/07 17 of 20
Texas Standardized Credentialing Application
Attachment E – Other Previous Hospital Affiliations
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES AFFILIATION DATES (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.) WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES AFFILIATION DATES (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.) WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES AFFILIATION DATES (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.) WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES AFFILIATION DATES (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.) WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES AFFILIATION DATES (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.) WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
PREVIOUS HOSPITAL WHERE YOU HAVE HAD PRIVILEGES AFFILIATION DATES (MM/YYYY TO MM/YYYY)
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
FULL UNRESTRICTED PRIVILEGES?
Yes No
TYPES OF PRIVILEGES (PROVISIONAL, LIMITED, CONDITIONAL, ETC.) WERE PRIVILEGES TEMPORARY?
Yes No
REASON FOR DISCONTINUANCE
LHL234 Rev.01/07 18 of 20
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
OCATION ADDRESS
PRACTICE L Primary
CITY
STATE/COUNTRY POSTAL CODE
MAIL
PHONE NUMBER FAX NUMBER E-
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
Yes
No
DIRECTORY?
Yes
N
MB
o
OFFICE MANAGER OR STAFF CONTACT PHONE NUMBER FAX NU ER
CREDENTIALING CONTACT
ADDRESS
CITY
STATE/COUNTRY POSTAL CODE
PHONE NUMBER FAX NUMBER E-MAIL
BILLING COMPANY'S NAME (IF APPLICABLE) BILLING REPRESENTATIVE
ADDRESS
CITY
STATE/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
Monday No Office Hours Morning:
Afternoon:
Evening:
Tuesday No Office Hours Morning:
Afternoon:
Evening:
Wednesday No Office Hours Morning:
Afternoon:
Ev g:enin
Thursday No Office Hours Morning:
Afternoon:
Evening:
Friday
No Office Hours Morning:
Afternoon:
Evening:
Saturday No Office Hours Morning:
rn Afte oon:
Evening:
Sunda
y No Office Hours Morning:
e Aft rnoon: Evening:
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?
Yes No If yes, provide the following information for each staff member:
NAME PROFESSIONAL DESIGNATION STATE & LICENSE NUMBER
NAME PROFESSIONAL DESIGNATION STATE & LICENSE NUMBER
Texas Standardized Credentialing Application
Attachment F – Other Practice Locations
click to sign
signature
click to edit
Practice Location Information
- continued
NAME PROFESSIONAL DESIGNATION STATE & LICENSE
NUMBER
NAME PROFESSIONAL DESIGNATION STATE & LICENSE
NUMBER
NAME PROFESSIONAL DESIGNATION STATE & LICENSE
NUMBER
NAME PROFESSIONAL DESIGNATION STATE & LICENSE
NUMBER
NON-ENGLISH LANGUAGES SPOKEN BY HEALTH CARE PROVIDERS NON-ENGLISH LANGUAGES SPOKEN BY OFFICE PERSONNEL
ARE INTERPRETERS AVAILABLE?
Yes
No
If yes, please specify
languages:
DOES THIS PRACTICE LOCATION
MEET ADA ACCESSIBILITY STANDARDS?
WHICH OF THE FOLLOWING FACILITIES ARE HANDICAPPED ACCESSIBLE?
Ye
s No Building Parking Restroom
Other:
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 Other:
DOES THIS LOCATION PROVIDE CHILDCARE SERVICES?
DOES THIS LOCATION QUALIFY AS
A MINORITY BUSINESS ENTERPRISE?
Yes
No
Yes
No
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
Staff Provider Exp:
Advanced Trauma Life Support
St p:
i -Pulmonary Resuscitation aff Provider Ex Cardo Staff Provider Exp:
Advanced Cardiac Life Support
Staff Provider Exp:
Pediatric Advanced Life Support Staff Provider Exp:
Neonatal
Advanced Life Support
Staff Provider Exp:
Other (please specify)
Staff d Provi er Exp:
DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? Yes
No
Laboratory Services; please
list all
Certificates of Participation (CLIA, AAFP, COLA, CAP, MLE):
DOES THIS LOCATION PROVIDE ANY OF THE FOLLOWING SERVICES ON SITE? No Yes
X-ray; please
list all
certifications:
OTHER SERVICES
Radiolog c Care of Miy Servi es EKG nor Lacerations Pulmonary Function Tests
Allergy Injections
Allergy Skin Tests Routine
Office Gynecology
ng Blood
Age Appropriate Immunizations
Drawi
Flexible Sigmoidoscopy
Tympanometry/Audiometry Tests
T Asthma reatments
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? WHO ADMINISTERS IT?
Yes No Please specify the classes or categories:
Please
check this box and complete
and submit Attachment F if you have other practice locations.
LHL234 Rev.01/07 19 of 20
Attachment F (continued)
LHL234 Rev.01/07 20 of 20
INCIDENT DATE (MM/DD/YYYY) DATE CLAIM WAS FILED (MM/DD/YYYY)
CLAIM/CASE STATUS
PROFESSIONAL LIABILITY CARRIER
INVOLVED
ADDRESS
CITY STATE/COUNTRY POSTAL CODE
PHONE NUMBER POLICY NUMBER AMOUNT OF AWARD OR SETTLEMENT & AMOUNT PAID
$ $
METHOD OF RESOLUTION
Dismissed Settled (with prejudice) Settled (without prejudice)
Judgment for Defendant(s) Judgment for Plaintiff(s)
Mediation or Arbitration
DESCRIPTION OF ALLEGATIONS
WERE YOU PRIMARY DEFENDANT OR CO-DEFENDANT? NUMBER OF OTHER CO-DEFENDANTS YOUR INVOLVEMENT (ATTENDING, CONSULTING, ETC.)
DESCRIPTION OF ALLEGED INJURY TO THE PATIENT
TO THE BEST OF YOUR KNOWLEDGE, IS THIS CASE INCLUDED IN THE NATIONAL PRACTITIONER DATA BANK
(NPDB)?
Yes No
INCIDENT DATE (MM/DD/YYYY)
DATE CLAIM WAS FILED (MM/DD/YYYY)
CLAIM/CASE STATUS
PROFESSIONAL LIABILITY CARRIER
INVOLVED
ADDRESS
CITY
STATE/COUNTRY
POSTAL
CODE
PHONE NUMBER POLICY NUMBER AMOUNT OF AWARD OR SETTLEMENT & AMOUNT PAID
$ $
METHOD OF RESOLUTION
Dismissed Settled (with prejudice) Settled (without prejudice)
Judgment for Defendant(s) Judgment for Plaintiff(s)
Mediation or Arbitration
DESCRIPTION OF ALLEGATIONS
WERE YOU PRIMARY DEFENDANT OR CO-DEFENDANT? NUMBER OF OTHER CO-DEFENDANTS YOUR INVOLVEMENT (ATTENDING, CONSULTING, ETC.)
DESCRIPTION OF ALLEGED INJURY TO THE PATIENT
TO THE BEST OF YOUR KNOWLEDGE, IS THIS CASE INCLUDED IN THE NATIONAL PRACTITIONER DATA BANK
(NPDB)?
Yes No
Texas Standardized Credentialing Application
Attachment G – Malpractice Claims History
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Texas Standardized Credentialing Application (Please type or print) (Texas Real Estate Contracts)

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Completed 13 July 2021

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