Form LHL234 "Texas Standardized Credentialing Application" - Texas

What Is a Texas Standardized Credentialing Application?

Form LHL234, Texas Standardized Credentialing Application, is a form that should be completed by a physician, which applies to practice within a hospital in the state of Texas. This form is used by hospitals for verification of physician credentials. Credentialing is a process of assessing the background and legitimacy of medical professionals. No physician is allowed to practice within a hospital without clinical privileges.

This form was released by the Texas Department of Insurance and the latest version was issued on January 1, 2007. A Texas Standardized Credentialing Application (PDF) is available for download below.

ADVERTISEMENT

Texas Standardized Credentialing Application Instructions

The instructions for filling in an LHL234 are the following:

  1. Section I contains individual information of the applicant, including their name, mailing address, and phone number.
    • The applicant has to provide information about their education, including professional degree, all licenses and certifications received. Professional/specialty information should be indicated as well.
    • A chronological work history of the physician should be provided. If the applicant was unemployed for more than six months, the reasons for such a gap must be given.
    • The hospitals where the physician has their admitting privileges should be indicated.
    • Provide three peer references, which have the same specialty. It is not allowed to indicate a relative of the applicant in this section.
    • Information about professional liability insurance coverage and call coverage should be entered.
    • The medical professional has to answer questions regarding their practice location.
  2. Section II contains a list of disclosure questions. The applicant has to answer them "Yes" or "No". In case of answering "Yes" to any question except #16, the filer should explain such an answer on the space provided on page 10.
  3. Section III contains provisions regarding standard authorization, attestation, and release. The applicant should sign the form; print their name and the date of completing.
ADVERTISEMENT

Download Form LHL234 "Texas Standardized Credentialing Application" - Texas

455 times
Rate (4.8 / 5) 27 votes
Pursuant to Texas Insurance Code § 1452.052, LHL234 Rev. 01/07 is promulgated by the Texas Department of Insurance. Please send this
application to the carrier with whom you wish to become credentialed.
Texas Standardized Credentialing Application
(Please type or print)
Section I-Individual Information
TYPE OF PROFESSIONAL
LAST NAME
FIRST
MIDDLE
(JR., SR., ETC.)
MAIDEN NAME
YEARS ASSOCIATED (YYYY-YYYY)
OTHER NAME
YEARS ASSOCIATED (YYYY-YYYY)
HOME MAILING ADDRESS
CITY
STATE/COUNTRY
POSTAL CODE
HOME PHONE NUMBER
SOCIAL SECURITY NUMBER
Female
Male
CORRESPONDENCE ADDRESS
CITY
STATE/COUNTRY
POSTAL CODE
PHONE NUMBER
FAX NUMBER
E-MAIL
DATE OF BIRTH (MM/DD/YYYY)
PLACE OF BIRTH
CITIZENSHIP
IF NOT AMERICAN CITIZEN, VISA NUMBER & STATUS
ARE YOU ELIGIBLE TO WORK IN THE UNITED STATES?
Yes
No
U.S.MILITARY SERVICE/PUBLIC HEALTH
DATES OF SERVICE (MM/DD/YYYY) TO
LAST LOCATION
Ye
s
No
(MM/D /YYYY)
D
BRANCH OF SERVICE
ARE YOU CURRENTLY ON ACTIVE OR RESERVE MILITARY DUTY?
Yes
No
Education
PROFESSIONAL DEGREE (MEDICAL, DENTAL, CHIROPRACTIC, ETC.)
Issuing Institution:
ADDRESS
CIT
Y
STATE/COUNTRY
POSTAL CODE
DEGREE
ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
Please check this box and complete and submit Attachment A if you received other professional degrees.
POST-GRADUATE EDUCATION
SPECIALTY
Internship
Residency
Fellowship
Teaching Appointment
INSTITUTION
ADDRESS
CITY
STATE/COUNTRY
POSTAL CODE
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
A
DDRESS
CITY
STATE/COUNTRY
POSTAL CODE
LHL234 Rev.01/07
1 of 20
Pursuant to Texas Insurance Code § 1452.052, LHL234 Rev. 01/07 is promulgated by the Texas Department of Insurance. Please send this
application to the carrier with whom you wish to become credentialed.
Texas Standardized Credentialing Application
(Please type or print)
Section I-Individual Information
TYPE OF PROFESSIONAL
LAST NAME
FIRST
MIDDLE
(JR., SR., ETC.)
MAIDEN NAME
YEARS ASSOCIATED (YYYY-YYYY)
OTHER NAME
YEARS ASSOCIATED (YYYY-YYYY)
HOME MAILING ADDRESS
CITY
STATE/COUNTRY
POSTAL CODE
HOME PHONE NUMBER
SOCIAL SECURITY NUMBER
Female
Male
CORRESPONDENCE ADDRESS
CITY
STATE/COUNTRY
POSTAL CODE
PHONE NUMBER
FAX NUMBER
E-MAIL
DATE OF BIRTH (MM/DD/YYYY)
PLACE OF BIRTH
CITIZENSHIP
IF NOT AMERICAN CITIZEN, VISA NUMBER & STATUS
ARE YOU ELIGIBLE TO WORK IN THE UNITED STATES?
Yes
No
U.S.MILITARY SERVICE/PUBLIC HEALTH
DATES OF SERVICE (MM/DD/YYYY) TO
LAST LOCATION
Ye
s
No
(MM/D /YYYY)
D
BRANCH OF SERVICE
ARE YOU CURRENTLY ON ACTIVE OR RESERVE MILITARY DUTY?
Yes
No
Education
PROFESSIONAL DEGREE (MEDICAL, DENTAL, CHIROPRACTIC, ETC.)
Issuing Institution:
ADDRESS
CIT
Y
STATE/COUNTRY
POSTAL CODE
DEGREE
ATTENDANCE DATES(MM/YYYY TO MM/YYYY)
Please check this box and complete and submit Attachment A if you received other professional degrees.
POST-GRADUATE EDUCATION
SPECIALTY
Internship
Residency
Fellowship
Teaching Appointment
INSTITUTION
ADDRESS
CITY
STATE/COUNTRY
POSTAL CODE
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
A
DDRESS
CITY
STATE/COUNTRY
POSTAL CODE
LHL234 Rev.01/07
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)
LHL234 Rev.01/07
2 of 20
Professional/Specialty Information
-continued
IF NOT BOARD CERTIFIED, INDICATE ANY OF THE FOLLOWING THAT APPLY.
I have taken exam, results pending for
Board.
I have taken Part I and am eligible for Part II of the
Exam.
I am intending to sit for the Boards on
(date)
I am not planning to take Boards.
DO YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY?
HMO:
Yes
No PPO:
Ye
s
No
PO :
S
Yes
No
ADDITIONAL SPECIALTY
BOARD CERTIFIED?
Yes
No
Name of Certifying Board:
INITIAL CERTIFICATION DATE (MM/YYYY)
RECERTIFICATION DATE(S), IF APPLICABLE (MM/YYYY)
EXPIRATION DATE, IF APPLICABLE (MM/YYYY)
IF NOT BOARD CERTIFIED, INDICATE ANY OF THE FOLLOWING THAT APPLY.
I
have tak n exam
e
, results pending for
Board.
I have taken Part I and am eligible for Part II of the
Exam.
I am intending to sit for the Boards on
(date)
I am not planning to take Boards.
DO YOU WISH TO BE LISTED IN THE DIRECTORY UNDER THIS SPECIALTY?
HMO:
Yes
No PPO:
Yes
No
POS:
Yes
No
PLEASE LIST OTHER AREAS OF PROFESSIONAL PRACTICE INTEREST OR FOCUS (HIV/AIDS, ETC.)
Work History
- Please provide a chronological work history. You may submit a Cu rriculum Vitae as
a supplement. Please explain all gaps in employment that lasted more than six months .
CURRENT PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDR
ESS
CITY
STATE/COUN TRY
POSTAL CODE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY
STATE/COUN TRY
POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY
STATE/COUN TRY
POSTAL CODE
REASON FOR DISCONTINUANCE
PREVIOUS PRACTICE/EMPLOYER NAME
START DATE/END DATE (MM/YYYY TO MM/YYYY)
ADDRESS
CITY
STATE/COUN TRY
POSTAL CODE
REASON FOR DISCONTINUANCE
PLEASE PROVIDE AN EXPLANATION FOR ANY GAPS GREATER THAN SIX MONTHS (MM/YY YY TO MM/YYYY) IN WORK HISTORY.
Gap Dates:
Explanation:
Explanation:
Gap Dates:
LHL234 Rev.01/07
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
-Please include all hospitals w here you currently have or have previously had privileges.
Hospital Affiliations
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/COUN
TRY
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
PHONE NUMBER
NAME/TITLE
ADDRESS
CITY
STATE/COUNTRY
POSTAL CODE
LHL234 Rev.01/07
4 of 20
References
- continued
2
PHONE NUMBER
NAME/TITLE
ADDRESS
CITY
STATE/COUNTRY
POSTAL CODE
3
PHONE NUMBER
NAME/TITLE
ADDRESS
CITY
STATE/COUNTRY
POSTAL CODE
Professional Liability Insurance Coverage
SELF-INSURED?
NAME OF CURRENT MALPRACTICE INSURANCE CARRIER OR SELF-INSURED ENTITY
Yes
No
ADDRESS
CITY
STATE/COUNTRY
POSTAL CODE
PHONE NUMBER
POLICY NUMBER
EFFECTIVE DATE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
AMOUNT OF COVERAGE PER
AMOUNT OF COVERAGE AGGREGATE
TYPE OF COVERAGE
LENGTH OF TIME WITH CARRIER
OCCURRENCE
Individual
Shared
NAME OF PREVIOUS MALPRACTICE INSURANCE CARRIER IF WITH CURRENT CARRIER LESS THAN 5 YEARS
ADDRESS
CITY
STATE/COUNTRY
POSTAL CODE
PHONE NUMBER
POLICY NUMBER
EFFECTIVE DATE (MM/DD/YYYY)
EXPIRATION DATE (MM/DD/YYYY)
AMOUNT OF COVERAGE PER
AMOUNT OF COVERAGE AGGREGATE
TYPE OF COVERAGE
LENGTH OF TIME WITH CARRIER
OCCURRENCE
Individual
Shared
Call Coverage
See attached list of hospital staff within my department I utilize for call coverage.
PLEASE LIST NAMES OF COLLEAGUE(S) PROV IDING REGULAR COVERAGE AND HIS OR HER SPECIALTIES.
Name:
Specialty:
Name:
Specialty:
Name:
Specialty:
Name:
Specialty:
Name:
Specialty:
PLEASE LIST FULL NAMES OF ALL PARTNERS IN YOUR PRACTICE.
CHECK THIS BOX AND ATTACH LIST FOR LARGE GROUP.
Name:
Name:
Name:
Name:
Name:
Name:
Name:
Name:
LHL234 Rev.01/07
5 of 20