Fill Your Texas Credentialing Application Form Launch Texas Credentialing Application Editor Now

Fill Your Texas Credentialing Application Form

The Texas Credentialing Application form is a standardized document required for professionals seeking credentialing with insurance carriers in Texas. It is issued by the Texas Department of Insurance and must be submitted to the relevant carrier. Completing this application is a crucial step in establishing your professional credentials in the state.

Ready to get started? Fill out the Texas Credentialing Application form by clicking the button below.

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Article Guide

Dos and Don'ts

When filling out the Texas Credentialing Application form, attention to detail is crucial. Here are some important dos and don’ts to keep in mind:

  • Do read the entire application carefully before starting.
  • Do provide accurate and complete information for each section.
  • Do ensure that your contact information is current and correct.
  • Do check all dates for accuracy, especially for your education and work history.
  • Don't leave any sections blank unless instructed to do so.
  • Don't use abbreviations or acronyms that may not be universally understood.
  • Don't forget to sign and date the application before submission.
  • Don't submit the application without reviewing it for errors or omissions.

Sample - Texas Credentialing Application Form

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

 

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?

 

 

 

 

 

 

 

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Education

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROFESSIONAL DEGREE (MEDICAL, DENTAL, CHIROPRACTIC, ETC.)

 

 

 

 

Issuing Institution:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

STATE/COUNTRY

 

 

POSTAL CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 OF 20

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)

 

 

 

 

 

 

 

 

 

 

 

 

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:

Yes

No

POS:

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.

 

 

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

 

 

 

 

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

 

 

 

 

 

 

 

 

STATE/COUNTRY

POSTAL CODE

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

PLEASE PROVIDE AN EXPLANATION FOR ANY GAPS GREATER THAN SIX MONTHS (MM/YYYY TO MM/YYYY) IN WORK HISTORY.

Gap Dates:

 

Explanation:

 

 

 

 

 

Gap Dates:

 

Explanation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 OF 20

Work History – continued

Gap Dates:

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 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?

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

PRIMARY HOSPITAL WHERE YOU HAVE ADMITTING 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 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

4 OF 20

References- continued

2NAME/TITLE

ADDRESS

PHONE NUMBER

CITY

STATE/COUNTRY

POSTAL CODE

3NAME/TITLE

PHONE NUMBER

ADDRESS

CITYSTATE/COUNTRYPOSTAL 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) PROVIDING 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:

 

 

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 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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

STATE/COUNTRY

 

 

 

 

POSTAL CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE NUMBER

 

 

 

 

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:

 

 

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?

 

 

 

 

 

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 NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

 

 

 

PROFESSIONAL DESIGNATION

 

 

 

 

STATE & LICENSE NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

Staff

 

Provider Exp:

 

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

 

Provider 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.

7 OF 20

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?

 

Yes

No

2

Have you ever received a reprimand or been fined by any state licensing board?

 

 

Yes

No

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?

Yes No

4Have you voluntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?

Yes No

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)?

Yes No

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?

Yes No

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?

Yes No

8Have any of your board certifications or eligibility ever been revoked?

Yes No

9Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?

Yes No

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?

Yes No

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?

Yes No

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?

Yes No

8 OF 20

Section II - Disclosure Questions - continued

Other Sanctions or Investigations

13To 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

14Have you ever received sanctions from or been the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)?

Yes No

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?

Yes No

Malpractice Claims History

16Have you had any malpractice actions within the past 5 years (pending, settled, arbitrated, mediated or litigated?

Yes No

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?

Yes No

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?

Yes No

19Have you been court-martialed for actions related to your duties as a medical professional?

Yes No

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.)

Yes No

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?

Yes No

Ability to Perform Job

22Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients?

Yes No

23Are 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

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Documents used along the form

The Texas Credentialing Application form is an essential document for healthcare professionals seeking to establish their credentials with insurance carriers in Texas. Along with this application, several other forms and documents are commonly required to ensure a comprehensive review of the applicant's qualifications and background. Below is a list of these important documents.

  • Attachment A: Additional Professional Degrees - This document is used to provide details about any additional professional degrees that the applicant may hold, beyond what is listed in the main application. It includes information about the issuing institution and the dates of attendance.
  • Attachment B: Additional Postgraduate Training - If the applicant has completed any additional postgraduate training, this attachment captures that information. It outlines the specialty, institution, and dates of attendance, ensuring a complete picture of the applicant's education.
  • Attachment C: Additional Work History - This form is necessary if the applicant has more work history to report than what fits in the main application. It allows for a detailed account of previous employment, including reasons for discontinuation and gaps in employment.
  • Attachment D: Additional Current Hospital Affiliations - If the applicant has current hospital affiliations beyond those listed in the main application, this document is used to provide that information. It includes details about the hospital, types of privileges, and any relevant dates.

Completing these additional documents accurately can significantly enhance the application process, providing a thorough understanding of the applicant's qualifications. By ensuring all relevant information is submitted, applicants can facilitate a smoother credentialing experience.

Common mistakes

Filling out the Texas Credentialing Application form can be a daunting task. Many applicants make mistakes that can delay the credentialing process or even result in rejection. Understanding these common pitfalls can help ensure a smoother application experience.

One frequent error is incomplete personal information. Applicants often forget to fill in all required fields, such as the maiden name or social security number. Missing information can lead to unnecessary delays, as the reviewing party may have to reach out for clarification.

Another common mistake is inaccurate dates. When listing education and work history, it is essential to provide precise attendance and employment dates. Inconsistencies can raise red flags and may cause the application to be questioned or rejected.

Many applicants also fail to provide complete licensing information. It’s crucial to include all licenses and certifications from every state where the applicant has practiced. Omitting even one license can lead to complications in the verification process.

Additionally, not explaining gaps in employment can be problematic. If there are any breaks in work history that exceed six months, applicants should provide a brief explanation. This transparency can help mitigate concerns and demonstrate accountability.

Another oversight involves neglecting to update contact information. Providing current addresses, phone numbers, and email addresses is vital. If the credentialing body cannot reach the applicant, it could stall the process.

Furthermore, failing to check for accuracy before submission can lead to errors. It is advisable to review the entire application thoroughly. Simple typos or incorrect information can cause significant setbacks.

Lastly, not providing peer references as required can hinder the application. Applicants should ensure they list three peer references who can vouch for their qualifications and character. This is an essential part of the credentialing process that should not be overlooked.

By avoiding these common mistakes, applicants can enhance their chances of a successful credentialing experience in Texas. Careful attention to detail and thoroughness in completing the application will pave the way for a smoother process.

Misconceptions

  • Misconception 1: The Texas Credentialing Application is only for medical professionals.

    • This application is designed for a variety of healthcare providers, not just those in medicine. It encompasses professionals from dental, chiropractic, and other health-related fields, ensuring a broad range of practitioners can seek credentialing.

  • Misconception 2: You must have completed all postgraduate training before applying.

    • While it's beneficial to have completed your training, the application allows you to indicate your current educational status. If you're still in training, you can specify your program and expected completion dates.

  • Misconception 3: The application process is overly complicated and time-consuming.

    • Though the application may seem extensive, it is structured to gather essential information efficiently. Taking it step-by-step can simplify the process, and many applicants find that gathering their documents beforehand can make completion quicker.

  • Misconception 4: You don’t need to provide references if you have extensive work experience.

    • Even seasoned professionals are required to submit peer references. These references offer insight into your skills and character, which is valuable for the credentialing body.

  • Misconception 5: Your application will be automatically approved if you meet the basic requirements.

    • Meeting the basic requirements is just the first step. The application undergoes a thorough review process, and various factors, including completeness and accuracy, will influence the final decision.

Free Texas Credentialing Application File

Key takeaways

Filling out the Texas Credentialing Application form can seem daunting, but understanding its key components can simplify the process. Here are some essential takeaways to keep in mind:

  • Accurate Personal Information: Ensure that all personal details, including your name, address, and contact information, are accurate. Mistakes can lead to delays in the credentialing process.
  • Education and Training: Provide comprehensive details about your educational background. This includes your degrees, institutions attended, and dates of attendance. Any gaps in education should be clearly explained.
  • Licenses and Certifications: List all licenses and certifications from every state where you have practiced. Include the type, number, and expiration dates to avoid any confusion.
  • Work History: Present a chronological work history. If there are gaps longer than six months, be prepared to explain them. A Curriculum Vitae can be submitted as a supplement.
  • Hospital Affiliations: Clearly indicate your current and past hospital privileges. Include details about the type of privileges you hold and whether they are temporary or permanent.
  • References: Provide three peer references who can vouch for your professional abilities. Ensure they are not relatives or partners in your practice to maintain objectivity.

By focusing on these key areas, you can complete the Texas Credentialing Application form more effectively, paving the way for a smoother credentialing experience.

File Characteristics

Fact Name Description
Form Title The form is titled "Texas Standardized Credentialing Application." It is essential for professionals seeking credentialing in Texas.
Governing Law This application is governed by the Texas Insurance Code § 1452.052, ensuring compliance with state regulations.
Submission Requirement Applicants must send this application to the insurance carrier with whom they wish to become credentialed.
Personal Information Section Section I requires detailed personal information, including full name, contact details, and citizenship status.
Education Details The form requests information about professional degrees and postgraduate education, including attendance dates and institutions.
Licenses and Certifications Applicants must provide details of all licenses and certifications from any state where they are currently or have previously been licensed.
Work History A chronological work history is required, including explanations for any employment gaps exceeding six months.
References Requirement Three peer references are needed, and they must have firsthand knowledge of the applicant's abilities in the same field or specialty.

How to Use Texas Credentialing Application

Completing the Texas Credentialing Application form is a straightforward process. Follow the steps below to ensure you provide all necessary information accurately. After filling out the form, submit it to the carrier with whom you wish to become credentialed.

  1. Begin with Section I, and fill in your Individual Information. Include your name, maiden name, and any other names you have used. Provide your home mailing address and contact details.
  2. Indicate your gender and date of birth, and provide your place of birth and citizenship status. If applicable, include your visa number and work eligibility in the U.S.
  3. Complete the section on U.S. Military Service/Public Health, if relevant. Fill in the dates of service and branch of service.
  4. Move on to the Education section. List your professional degree, the issuing institution, and the attendance dates. If you have other professional degrees, check the box and complete Attachment A.
  5. Provide details about your postgraduate education, including internships, residencies, and fellowships. Include the institution, attendance dates, and program director information.
  6. In the Licenses and Certificates section, list all licenses and certifications. Include the type, number, state of registration, issue dates, and expiration dates. Confirm whether you currently practice in that state.
  7. Fill out the Professional/Specialty Information section. Indicate your primary specialty and whether you are board certified. Provide certification dates and any additional specialties.
  8. Detail your Work History chronologically. Include current and previous employers, start and end dates, addresses, and reasons for discontinuation if applicable.
  9. Answer questions regarding Hospital Affiliations. Indicate if you have hospital privileges and provide details about your primary and any other hospitals where you have privileges.
  10. Provide References from three peers in your field. Include their names, titles, contact information, and addresses.
  11. Complete the Professional Liability Insurance Coverage section. Indicate if you are self-insured, and provide details about your current and previous malpractice insurance carriers.
  12. Finally, list colleagues providing regular call coverage and the names of all partners in your practice. If you have a large group, check the box and attach a list.