Modify Texas Credentialing Application Here

Texas Credentialing Application Form in PDF

The Texas Credentialing Application form, identified as LHL234 | 01/07, serves as a standardized document for professionals seeking credentialing in Texas, in accordance with the Texas Insurance Code § 1452.052. Developed by the Texas Department of Insurance, this comprehensive form is a critical step for individuals aiming to establish their credentials and affiliate with carriers in Texas. To begin the process of becoming credentialed and to ensure compliance with state requirements, applicants are encouraged to meticulously fill out and submit this application to their desired carrier.

To take the first step towards credentialing in Texas, click the button below.

Modify Texas Credentialing Application Here

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The Texas Standardized Credentialing Application, known as LHL234 revision 01/07, plays a critical role in the approval process for professionals aiming to be credentialed by insurers in Texas, following the guidelines set by the Texas Insurance Code § 1452.052. This detailed application, overseen by the Texas Department of Insurance, demands comprehensive personal and professional information from applicants. Starting with individual information including personal details, citizenship, and eligibility for work in the United States, it progresses to in-depth discussions on education, showcasing degrees, postgraduate education, and any further training. Licenses and certifications come next, requiring details of all state registrations, alongside DEA and DPS numbers, where applicable. The form delves into professional and specialty information, asking about board certifications, primary and secondary specialties, and any plans for board examination. It inquires about work history, including an explanation for any employment gaps, and hospital affiliations to ascertain the applicant's practical experience. Furthermore, it includes a section for professional liability insurance coverage details, demonstrating the applicant's preparedness in managing potential liabilities. The necessity for peer references and a thorough work history aims to provide a thorough background check, ensuring that only the most qualified individuals are considered for credentialing. The form is a comprehensive tool designed to streamline the credentialing process, ensuring that professionals meet the high standards required by the Texas Department of Insurance and insurance carriers.

Texas Credentialing Application Sample

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)

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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.

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

DIRECTORY?

Yes

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

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

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

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

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

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

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

⇩ PDF File

File Characteristics

Fact Name	Description
Form Identification	The form is labeled as LHL234, revision date 01/07.
Governing Law	It is promulgated under Texas Insurance Code § 1452.052.
Issuing Body	The Texas Department of Insurance is responsible for the form's issuance.
Submission Instructions	Applicants are instructed to send the completed application to the carrier they wish to become credentialed with.
Sections Covered	Includes Individual Information, Education, Licenses and Certificates, Professional/Specialty Information, Work History, Hospital Affiliations, References, and Professional Liability Insurance Coverage.
Special Features	Attachments A, B, C, D, E are mentioned for providing additional information regarding education, postgraduate training, work history, current, and previous hospital affiliations respectively.

Detailed Guide for Writing Texas Credentialing Application

Filling out the Texas Credentialing Application form is an essential step for healthcare providers who are looking to be recognized by insurance carriers in Texas. This process, although it might seem daunting at first due to its comprehensive nature, is crucial for ensuring that patients can use their health insurance with your services. By completing this form diligently, you're taking a significant step towards expanding your practice's accessibility and efficiency. Below is a guide to help you navigate through the form. Remember, accuracy and attention to detail will streamline your credentialing process.

Start with Section I - Individual Information. Provide your professional title, full name, including maiden and other names if applicable, and the years associated with each. Also, include your home mailing address, contact numbers, email, date and place of birth, citizenship status, and if you're eligible to work in the U.S.
Fill out your U.S. Military Service/Public Health Service Information if applicable, including dates of service, last location, and branch of service. Indicate whether you are currently on active or reserve military duty.
In the Education section, start with your professional degree(s), including issuing institution, location, attendance dates, and any post-graduate education details like specialty, institution, and program director. Check the corresponding box if you have additional degrees or postgraduate training to include from attachments A and B.
Under Licenses and Certificates, list all professional licenses and certifications you hold, including type, number, state of registration, issue, and expiration dates. Include information about your DEA and DPS numbers if applicable, as well as your UPIN and national provider identifier. Mention your status as a participating Medicare or Medicaid provider.
Detail your Professional/Specialty Information, indicating your primary and secondary specialties, board certification status, certifying board names, and certification dates. If not board certified, specify your current status regarding the board examination.
For the Work History section, provide a chronological list of your employment, starting with the current or most recent. Include employer name, starting and ending dates, address, and reason for discontinuance. Explain any employment gaps greater than six months.
In Hospital Affiliations, list all hospitals where you currently or previously had privileges. State whether you have full unrestricted privileges and the types of privileges held. If you have other current or previous hospital affiliations, indicate those on Attachment D or E as necessary.
Provide three peer references from the same field and/or specialty. These references should not be partners in your group practice or relatives. Include their full names, titles, contact information, and addresses.
Detail your Professional Liability Insurance Coverage, including whether you are self-insured, the name of your current malpractice insurance carrier, policy number, effective and expiration dates, and amount of coverage. If you have been with your current carrier for less than five years, provide information regarding your previous carrier as well.
Lastly, provide information regarding Call Coverage and list full names of all partners in your practice. Attach a separate list if you belong to a large group.

Before submitting the form, double-check all entered information for accuracy and completeness. Ensure that any additional documents or attachments required are completed and included with your application. Once ready, send the application to the carrier with whom you wish to become credentiated. Taking the time to fill out this form thoroughly and accurately is a step towards establishing a strong foundation for your practice within the Texas healthcare system.

Common Questions

What is the Texas Standardized Credentialing Application?

The Texas Standardized Credentialing Application (LHL234 Rev. 01/07) is a form designed for professionals who wish to be credentialed with insurance carriers in Texas. It's mandated by the Texas Insurance Code § 1452.052 and created by the Texas Department of Insurance. Professionals must complete and submit this application to the carrier with whom they wish to become credentiled.

How do I submit the Texas Credentialing Application form?

After completing the Texas Credentialing Application form, it should be sent directly to the insurance carrier you wish to be aligned with. Ensure every section is completed accurately to avoid delays in the processing of your application.

What information do I need to provide in the Texas Credentialing Application?

You are required to provide comprehensive details, which include:

Individual Information such as name, contact information, social security number, and work eligibility in the U.S.
Educational background including professional degrees, postgraduate education, and any other graduate-level education.
License and certificate information for all states where you have or had licensure.
Work history along with explanations for any employment gaps exceeding six months.
Hospital affiliations, both current and past.
Professional liability insurance coverage details.
Names and contact information for three peer references.

What happens if I have additional information that doesn't fit on the form?

If you have more information than the form allows, specific sections like Education, Work History, Hospital Affiliations, and Professional Liability Insurance Coverage have checkboxes that, when marked, request you to attach additional documents. Make sure these attachments are clearly labeled and included with your application.

Do I need to include all licenses, even if they are not active?

Yes, you must include information on all licenses in every state where you are currently or have previously been licensed, regardless of their current status. This provides a complete picture of your professional background.

What if I have gaps in my work history?

You are required to provide explanations for any gaps in employment that lasted more than six months. Make sure to include the specific dates and reasons for these gaps in your work history section.

Who should I list as references?

You should list three peer references from the same field and/or specialty who are not partners in your own group practice and are not related to you. These references should have firsthand knowledge of your professional abilities.

Is it mandatory to have hospital privileges to submit the application?

No, it’s not mandatory to have hospital privileges to submit the application. However, if you do not have admitting privileges, you must outline what admitting arrangements you have in place.

How do I indicate if I’m board certified in a specialty?

In the Professional/Specialty Information section, specify if you are board certified in your primary and any additional specialties. For those not board certified, indicate whether you've taken the exam, are waiting for results, are eligible for part II of the exam, plan to sit for the board exam, or do not plan to take it. Also, include the name of the certifying board and certification dates where applicable.

What should I do if I have more than one professional degree or additional postgraduate training?

If you have received more than one professional degree or have additional postgraduate training, check the appropriate box in the Education section and attach the required Attachment A or B, detailing the additional education.

Common mistakes

When filling out the Texas Credentialing Application form, there are common mistakes that can lead to complications or delays in the processing of the application. It's important to avoid these errors:

Not providing complete responses in sections such as Individual Information, Education, and Licenses and Certificates. Every field must be completed accurately.
Using inconsistent information across different sections, which can cause confusion or signal potential inaccuracies in your application.
Failing to check if additional documentation is needed, like in sections that require attaching more details for Education or Work History.
Omitting details about previous or current licensures in States other than Texas, which could be perceived as withholding important professional information.
Incorrectly listing dates in formats other than MM/DD/YYYY or MM/YYYY, which is the standard required by the application.
Incomplete descriptions of work history, especially not explaining gaps in employment longer than six months, which is specifically asked for in the form.
Skipping the section on Professional Liability Insurance Coverage, which is crucial for assessing your professional standing and risk.
Not providing accurate contact information for references, or choosing references that do not meet the criteria stipulated, such as those being relatives or not having firsthand knowledge of your abilities.

To ensure a smooth credentialing process, it is vital to:

Double-check all entries for completeness and accuracy.
Adhere to the specific requirements for dates and document formats.
Provide all necessary supplementary documents, especially where indicated by checkboxes in the form.
Ensure that all references are qualified, as per the application's instructions.

By avoiding these common pitfalls, applicants can expect a more efficient review of their credentialing application, facilitating a faster integration into the healthcare system in Texas.

Documents used along the form

When handling the Texas Credentialing Application form, it's crucial to gather and prepare several supporting documents and forms that are commonly required in the credentialing process. These documents are essential for verifying the qualifications, experience, and professional background of healthcare providers. Here is a list of other forms and documents often used along with the Texas Credentialing Application form:

Curriculum Vitae (CV): Provides a comprehensive overview of the applicant's educational background, work history, certifications, and other professional achievements.
Professional Licenses: Copies of current and past professional licenses verify the legal ability to practice in the medical field within Texas or other states.
Board Certification Documentation: Proof of board certification validates the provider's specialty qualifications and expertise.
Malpractice Insurance Coverage: Documentation of current malpractice insurance policy, including policy number, effective dates, and coverage amounts.
Continuing Medical Education (CME) Credits: Records of CME credits support ongoing education and expertise in the provider's specialty area.
DEA and DPS Certificates: Federal (DEA) and state (DPS) controlled substance registration certificates are required for prescribing medications.
Work History Documentation: Detailed records or an attachment explaining any gaps in employment, as required in the Texas Credentialing Application.
Peer References: Letters or forms from peers in the same specialty, providing verification of professional competence and good standing.

Each of these documents plays a vital role in the credentialing process, contributing to a holistic view of the applicant's qualifications and suitability for practice. Together with the Texas Credentialing Application form, these documents ensure a thorough and accurate assessment of the healthcare provider's background, thereby upholding the standards of care and professionalism in the medical community.

Similar forms

The National Provider Identifier (NPI) Application is similar to the Texas Credentialing Application form in that both require detailed personal and professional information from healthcare providers, including their educational background, licensure, and certification. The NPI Application is used to assign a unique identification number to healthcare providers across the U.S., facilitating billing and record-keeping processes in line with federal regulations.

The Medical License Application, offered by state medical boards, shares similarities with the Texas Credentialing Application by asking for extensive details on an applicant's medical education, training, and current and past licenses. These applications ensure that practitioners meet state-specific requirements to practice medicine and protect public health and safety.

The Provider Enrollment, Chain, and Ownership System (PECOS) Application is used by healthcare providers to enroll in Medicare, mirroring the Texas Credentialing Application in its requirement for detailed professional information. Both forms play pivotal roles in verifying the qualifications of healthcare professionals to ensure they meet respective federal and state requirements for providing medical services.

The Hospital Privileges Application, which healthcare providers complete to obtain admitting privileges at hospitals, parallels the Texas Credentialing Application in its request for detailed education, training, and licensure information. This process is crucial for hospitals to verify the qualifications of their medical staff to maintain high standards of patient care.

The DEA Registration Application for prescribing controlled substances is akin to the Texas Credentialing Application form in its need for detailed professional credentials. While the former specifically addresses the authorization to handle controlled substances, both forms are integral to regulatory compliance and ensuring the qualifications of healthcare providers.

The Council for Affordable Quality Healthcare (CAQH) ProView Application, designed to streamline healthcare provider credentialing, mirrors the Texas Credentialing Application by collecting comprehensive professional data. Both aim to simplify the credentialing process for providers and health plans, although CAQH ProView serves a broader, nationwide audience.

The Dental License Application, similar to its medical counterpart but aimed at dentists seeking to practice, requires extensive educational and professional details, akin to the Texas Credentialing Application. Both ensure that dental and medical professionals possess the necessary qualifications to provide safe and effective care.

The Professional Liability Insurance Application, while primarily focused on insurance aspects, requires detailed professional information similar to the Texas Credentialing Application. It assesses a healthcare provider’s background to determine risk and insurance premium rates, emphasizing the importance of a comprehensive professional history.

The Fellowship Application for postgraduate training in medical specialties closely resembles the Texas Credentialing Application in its requirement for exhaustive professional detail. Both applications assess the qualifications of healthcare providers but with different end goals: enhancing specialized medical knowledge versus credentialing for insurance purposes.

The Board Certification Application from various medical boards demands in-depth professional information, paralleling the Texas Credentialing Application form. It signifies a provider’s expertise in specific medical specialties, reinforcing the emphasis on thorough vetting in healthcare professionals' credentialing and certification processes.

Dos and Don'ts

Filling out the Texas Credentialing Application form accurately and thoroughly is essential for healthcare professionals seeking credentials in Texas. To ensure a smooth application process, here are some key dos and don'ts:

Do double-check that all the information provided is current and accurate. Mistakes can lead to delays in the credentialing process.
Do provide complete information for each section required. Incomplete applications may not be processed.
Do verify all dates and timelines mentioned, such as professional degrees, licenses, and certificates, to ensure they are correctly formatted (MM/DD/YYYY for dates).
Do include all necessary attachments, such as Attachment A for additional professional degrees, to support your application.
Do explain any gaps in employment that lasted more than six months as requested in the Work History section.
Do ensure that the list of references comes from peers in your field or specialty who are not partners in your practice and who have firsthand knowledge of your abilities.
Do sign and date the application, if a signature is required, to certify the accuracy of the information provided.

Don't forget to list all states where you are or have been licensed, including any licenses that may not be currently active.
Don't skip details on professional liability insurance coverage. This information is crucial for credentialing.
Don't omit any requested details about postgraduate education, including the institution's address and program director’s name, if known.
Don't leave the section on board certification incomplete. If you are not board certified, clarify your status regarding board examinations.
Don't ignore the instructions for attaching additional information if you've exceeded the capacity of any section (e.g., Attachment C for additional work history).
Don't neglect to provide specifics on the primary and secondary specialties under the Professional/Specialty Information section.
Don't omit contact information or addresses for any of the sections, including references, as this could delay the verification process.

By following these tips, applicants can enhance their chances of a successful credentialing process with the Texas Department of Insurance.

Misconceptions

Many professionals and applicants encounter misconceptions regarding the Texas Standardized Credentialing Application (LHL234 Rev. 01/07). Understanding these can streamline the process of applying and ensure accurate submissions. Here are ten common misconceptions explained:

Only for Physicians: While the form is often associated with physicians, it is actually intended for a range of healthcare professionals, including dentists, chiropractors, and more. The form is designed to be comprehensive, accommodating various types of professionals.
One-Time Submission: Some believe that once you submit the form, you're done forever. In reality, credentialing is an ongoing process requiring updates and re-submissions to reflect current qualifications, licenses, and practice information.
Immediate Processing: There is a belief that submissions are processed immediately. Due to the verification process and volume of applications, processing takes time. It’s important for applicants to submit well in advance of when they need to be credentialed.
Only Texas Residents Need Apply: This form is not solely for Texas residents. Any healthcare professional who wishes to be credentialed in Texas, regardless of their residency, needs to complete this form.
Citizenship Details Are Optional: Citizenship information is mandatory for credentialing purposes. This includes indicating whether you are eligible to work in the United States and providing visa status if you are not an American citizen.
Complete Curriculum Vitae Equals Exemption: Some believe that a comprehensive Curriculum Vitae (CV) exempts them from filling out the work history section thoroughly. However, the form requires specific details and dates that might not be covered in a CV.
Degree and License from Any State Are Acceptable: While having degrees and licenses from various states is permissible, each credential must be current and valid in the state of Texas or meet the Texas State Board’s criteria for practice.
All Sections Are Mandatory: Not all sections will apply to every applicant. It’s essential to read instructions carefully and only complete sections that are relevant to your professional credentials and requirements.
Submitting Additional Documents Is Unnecessary: Depending on your background, additional documents such as Attachment A for other professional degrees or Attachment C for more detailed work history might be required to supplement your application.
Only Need to List Texas Licenses and Certifications: Applicants must include all licenses and certifications, whether they are from Texas or other states, to provide a full picture of their credentials and facilitate the verification process.

Correcting these misconceptions can guide professionals through the credentialing application process more smoothly and ensure that their application is accurate and complete. This involves reading the application instructions carefully, preparing all necessary documents, and allowing sufficient time for processing.

Key takeaways

Filling out the Texas Credentialing Application form requires attention to detail and an understanding of specific requirements. Here are key takeaways to help guide individuals through this complex process:

Ensure accuracy in providing individual information, including your professional type, names you've been associated with, contact details, and citizenship status.
Detail your education background comprehensively, including degrees, post-graduate education, and any additional training or education you've received. Remember to submit Attachments A and B if applicable.
Licenses and certifications in all states where you have been or are currently licensed must be included, along with relevant numbers, original issue, and expiration dates.
Indicate your Medicare and Medicaid participation status and provide your Medicare Provider Number and Medicaid Provider Number if you are a participating provider.
For those with foreign medical degrees, provide your Educational Council for Foreign Medical Graduates (ECFMG) number and issue date where applicable.
Clearly state your professional/specialty information, including board certification details, initial certification date, and any recertification dates. Also, indicate if you wish to be listed in directories under these specialties.
Provide a chronological work history and explain any employment gaps greater than six months. You may supplement this section with a Curriculum Vitae.
Detail your hospital affiliations, including full unrestricted privileges and the percentage of admissions to each hospital, and submit Attachment D for additional current affiliations or Attachment E for previous affiliations.
Include information about your professional liability insurance coverage, indicating whether you are self-insured, the name of your insurance carrier, policy numbers, and coverage amounts.

Completing the Texas Credentialing Application form is a meticulous process that requires thoroughness and precision. By focusing on the key areas outlined above, applicants can ensure a smoother submission process. It's crucial to review each section carefully and comply with all specified requirements to facilitate the credentialing process.

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