Texas Standardized Credentialing Application …

1 Texas Standardized Credentialing Application ( please type or print)LHL234 02 Texas Department of Insurance1of 12 Section I Individual InformationTYPE OF PROFESSIONALLAST NAMEFIRSTMIDDLE(JR., SR., ETC.)MAIDEN NAMEYEARS ASSOCIATED(YYYY YYYY)OTHER NAMEYEARS ASSOCIATED(YYYY YYYY)HOME MAILING ADDRESSCITYSTATE COUNTRYPOSTAL CODEHOME PHONE NUMBERSOCIAL SECURITY NUMBERF emaleMaleCORRESPONDENCEADDRESSCITYSTATE COUNTRYPOSTAL CODEPHONE NUMBERFAX NUMBERE-MAILDATE OF BIRTH(MM DD YYYY)PLACE OF BIRTHCITIZENSHIPIF NOT AMERICAN CITIZEN, VISA NUMBER& STATUSARE YOU ELIGIBLE TO WORK IN THE UNITED STATES?Ye sN SERVICE PUBLIC HEALTHDATES OF SERVICE(MM DD YYYY)TO(MM DD YYYY)LAST LOCATIONYe sN oBRANCH OF SERVICEARE YOU CURRENTLY ON ACTIVE OR RESERVE MILITARY DUTY?

2 Ye sN oEducationPROFESSIONAL DEGREE(MEDICAL, DENTAL, CHIROPRACTIC, ETC.)Issuing Institution:ADDRESSCITYSTATE COUNTRYPOSTAL CODEDEGREEATTENDANCE DATES(MM YYYY TO MM YYYY) please check this box and complete and submit Attachment A if you received other professional EDUCATIONSPECIALTYI nternshipResidencyFellowshipTeaching AppointmentINSTITUTIONADDRESSCITYSTATE COUNTRYPOSTAL CODEATTENDANCE DATES(MM YYYY TO MM YYYY)Program successfully completedPROGRAM DIRECTORCURRENT PROGRAM DIRECTOR(IF KNOWN)POST-GRADUATE EDUCATIONSPECIALTYI nternshipResidencyFellowshipTeaching AppointmentINSTITUTIONADDRESSCITYSTATE COUNTRYPOSTAL CODEE ducation continuedPOST-GRADUATE EDUCATIONATTENDANCE DATES(MM YYYY TO MM YYYY)

3 Program successfully completedPROGRAM DIRECTORCURRENT PROGRAM DIRECTOR(IF KNOWN) please check this box and complete and submit Attachment B if you received additional post-graduate GRADUATE-LEVEL EDUCATIONI ssuing Institution:ADDRESSCITYSTATE COUNTRYPOSTAL CODEDEGREEATTENDANCE DATES(MM YYYY TO MM YYYY)Licenses and Certificates please include all license(s) and certifications in all States where you are currently orhave previously been TYPELICENSE NUMBERSTATE OF REGISTRATIONORIGINAL DATE OF ISSUE(MM DD YYYY)EXPIRATION DATE(MM DD YYYY)DO YOU CURRENTLY PRACTICE IN THIS STATE?Ye sN oLICENSE TYPELICENSE NUMBERSTATE OF REGISTRATIONORIGINAL DATE OF ISSUE(MM DD YYYY)EXPIRATION DATE(MM DD YYYY)DO YOU CURRENTLY PRACTICE IN THIS STATE?

4 Ye sN oLICENSE TYPELICENSE NUMBERSTATE OF REGISTRATIONORIGINAL DATE OF ISSUE(MM DD YYYY)EXPIRATION DATE(MM DD YYYY)DO YOU CURRENTLY PRACTICE IN THIS STATE?Ye sN oORIGINAL 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)NUMBERSTATE OF REGISTRATIONORIGINAL DATE OF ISSUE(MM DD YYYY)EXPIRATION DATE(MM DD YYYY)DO YOU CURRENTLY PRACTICE IN THIS STATE?Ye sN oUPINNATIONAL PROVIDER IDENTIFIER(WHEN AVAILABLE)ARE YOU A PARTICIPATING MEDICARE PROVIDER?ARE YOU A PARTICIPATING MEDICAID PROVIDER?YesNoMedicare Provider Number:Yes NoMedicaid Provider Number:EDUCATIONAL COUNCIL FOR FOREIGN MEDICAL GRADUATES(ECFMG)ECFMG ISSUE DATE(MM DD YYYY)N AYesNo ECFMG Number:Professional Specialty InformationPRIMARY SPECIALTYBOARD CERTIFIED?

5 YesNoName 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 have taken exam, results pending for .. have taken Part I and am eligible for Part II of the .. am intending to sit for the Boards on ..(date)I am not planning to take YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY?HMO: YesNoPPO: YesNoPOS: YesNoSECONDARY SPECIALTYBOARD CERTIFIED?YesNoName of Certifying Board:INITIAL CERTIFICATION DATE(MM YYYY)RECERTIFICATION DATE(S), IF APPLICABLE(MM YYYY)EXPIRATION DATE, IF APPLICABLE(MM YYYY)2of 12 Texas Department of InsuranceLHL234 02 Professional Specialty information continuedIF NOT BOARD CERTIFIED, INDICATE ANY OF THE FOLLOWING THAT have taken exam, results pending for.

6 Have taken Part I and am eligible for Part II of the .. am intending to sit for the Boards on ..(date)I am not planning to take YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY?HMO: YesNoPPO: YesNoPOS: YesNoADDITIONAL SPECIALTYBOARD CERTIFIED?Ye sNoName 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 have taken exam, results pending for .. have taken Part I and am eligible for Part II of the .. am intending to sit for the Boards on ..(date)I am not planning to take YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY?

7 HMO: YesNoPPO: YesNoPOS: YesNoPLEASE LIST OTHER AREAS OF PROFESSIONAL PRACTICE INTEREST OR FOCUS(HIV AIDS, ETC.)Work History please provide a chronological work histor y for the past 5 years. You may submit a Curriculum Vitae asa supplement. please explain all gaps in employment that lasted more than six PRACTICE EMPLOYER NAMESTART DATE END DATE(MM YYYY TO MM YYYY)ADDRESSCITYSTATE COUNTRYPOSTAL CODEPREVIOUS PRACTICE EMPLOYER NAMESTART DATE END DATE(MM YYYY TO MM YYYY)ADDRESSCITYSTATE COUNTRYPOSTAL CODEREASON FOR DISCONTINUANCEPREVIOUS PRACTICE EMPLOYER NAMESTART DATE END DATE(MM YYYY TO MM YYYY)ADDRESSCITYSTATE COUNTRYPOSTAL CODEREASON FOR DISCONTINUANCEPREVIOUS PRACTICE EMPLOYER NAMESTART DATE END DATE(MM YYYY TO MM YYYY)

8 ADDRESSCITYSTATE COUNTRYPOSTAL CODEREASON FOR DISCONTINUANCEPLEASE PROVIDE AN EXPLANATION FOR ANY GAPS GREATER THAN SIX MONTHS(MM YYYY TO MM YYYY) IN WORK Dates:Explanation:Gap Dates:Explanation:LHL234 02 Texas Department of Insurance3 of 12 Work History continuedGap Dates:Explanation:Gap Dates:Explanation: please check this box and complete and submit Attachment C if you have additional work Affiliations please include all hospitals where you currently have or have previously had YOU HAVE HOSPITAL PRIVILEGES?IF YOU DO NOT HAVE ADMITTING PRIVILEGES, WHAT ADMITTING ARRANGEMENTS DO YOU HAVE?Ye sN oPRIMARYHOSPITAL WHERE YOU HAVE ADMITTING PRIVILEGESSTART DATE(MM YYYY)ADDRESSCITYSTATE COUNTRYPOSTAL CODEPHONE NUMBERFAXE-MAILFULL UNRESTRICTED PRIVILEGES?

9 TYPES OF PRIVILEGES(PROVISIONAL, LIMITED, CONDITIONAL, ETC.)ARE PRIVILEGES TEMPORARY?Ye sN oYe sN oOF THE TOTAL NUMBER OF ADMISSIONS TO ALL HOSPITALS IN THE PAST YEAR, WHAT PERCENTAGE IS TO PRIMARY HOSPITAL?OTHERHOSPITAL WHERE YOU HAVE PRIVILEGESSTART DATE(MM YYYY)ADDRESSCITYSTATE COUNTRYPOSTAL CODEPHONE NUMBERFAXE-MAILFULL UNRESTRICTED PRIVILEGES?TYPES OF PRIVILEGES(PROVISIONAL, LIMITED, CONDITIONAL, ETC.)ARE PRIVILEGES TEMPORARY?Ye sN oYe sN oOF 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 currenthospital WHERE YOU HAVE HAD PRIVILEGESAFFILIATION DATES(MM YYYY TO MM YYYY)ADDRESSCITYSTATE COUNTRYPOSTAL CODEFULL UNRESTRICTED PRIVILEGES?

10 TYPES OF PRIVILEGES(PROVISIONAL, LIMITED, CONDITIONAL, ETC.)WERE PRIVILEGES TEMPORARY?Ye sN oYe sN oREASON FOR DISCONTINUANCEP lease check this box and complete and submit Attachment E if you have additional previoushospital please provide three peer references from the same field and or specialty who are not partners in your owngroup practice and are not relatives. All peer references should have firsthand knowledge of your NAME TITLEPHONE NUMBERADDRESSCITYSTATE COUNTRYPOSTAL CODE4 of 12 Texas Department of InsuranceLHL234 02 References continued2 NAME TITLEPHONE NUMBERADDRESSCITYSTATE COUNTRYPOSTAL CODE3 NAME TITLEPHONE NUMBERADDRESSCITYSTATE COUNTRYPOSTAL CODEP rofessional Liability Insurance CoverageSELF-INSURED?