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The Texas Credentialing Application Form (LHL234 Rev. 01/07) serves as a standardized tool for healthcare professionals seeking credentials in Texas, fulfilling requirements set by the Texas Insurance Code § 1452.052 and issued by the Texas Department of Insurance. It covers a comprehensive range of information, including personal details, education, licensure, professional history, hospital affiliations, and malpractice insurance details, which applicants submit to insurance carriers for credentialing purposes. Interested healthcare providers are encouraged to accurately complete and submit this form to facilitate their credentialing process efficiently.

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The Texas Credentialing Application form, identified as LHL234 and revised in January 2007, serves as a comprehensive tool for healthcare professionals seeking credentialing in the state of Texas. Mandated by the Texas Insurance Code § 1452.052 and promulgated by the Texas Department of Insurance, this form requires detailed information across several critical sections, including personal information, education, professional degrees, post-graduate training, licensure and certifications, Medicare and Medicaid participation, board certifications, professional practice focus, work history, hospital affiliations, professional liability insurance coverage, and peer references. This exhaustive document not only aids in standardizing the credentialing process but also ensures that professionals practicing in Texas meet the state's stringent criteria. Applicants must provide a chronological account of their educational background, work experience, and details of their professional certifications and licensure in all states where they have been licensed, highlighting the form's role in maintaining high standards of healthcare practice. Additionally, it encompasses questions regarding eligibility to work in the U.S., military service, and specific arrangements for admitting privileges, thereby accentuating its thoroughness in evaluating the credentials of healthcare providers. Submitting this application is a critical step for healthcare professionals to gain authorization to practice within Texas, underlining the form's importance in the Texas healthcare system's operational framework.

Document Example

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.

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

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Form Information

Fact Name	Detail
Form Identification	LHL234 \| 01/07 Texas Standardized Credentialing Application
Governing Law	Pursuant to Texas Insurance Code § 1452.052
Issuing Authority	Texas Department of Insurance
Primary Application Purpose	To be sent to the carrier with whom the individual wishes to become credentialed
Application Sections	Individual Information, Education, Licenses and Certificates, Professional/Specialty Information, Work History, Hospital Affiliations, References, Professional Liability Insurance Coverage
Eligibility for Work Verification	Question regarding eligibility to work in the United States is included
Military Service Inquiry	Questions about U.S. Military Service/Public Health Service included
Board Certification Information	Questions on board certification status, initial certification date, recertification dates, and board name are included
Professional Liability Insurance Coverage	Sections dedicated to both current and previous professional liability insurance coverage details

How to Use Texas Credentialing Application

Filling out the Texas Credentialing Application form is a crucial step for healthcare professionals aiming to establish their credentials in the state. This process, while detailed, opens the door to numerous opportunities within the Texas healthcare system. The instructions provided below are designed to guide applicants through each step of the application process, ensuring clarity and accuracy in providing the required information.

Start by entering your professional type (e.g., Medical, Dental) at the top of the form.
Fill in your name, including last, first, middle, maiden (if applicable), and any suffix (JR., SR., etc.) along with the years associated with each name.
Provide your home mailing address, including city, state/country, and postal code. Also, include your home phone number and social security number.
Mark your gender as either Female or Male.
Enter your correspondence address, if different from your home mailing address, including city, state/country, and postal code, along with a phone number, fax number, and email address.
Provide your date of birth, place of birth, and citizenship details. If you are not an American citizen, include your visa number and status.
Indicate if you are eligible to work in the United States.
Fill out the section about U.S. military service/public health service including dates of service, branch, and if you are currently on active or reserve duty.
Under the Education section, input details about your professional degree including issuing institution, address, attendance dates, and any post-graduate education including specialty, institution, and program details.
For Licenses and Certificates, list all license(s) and certifications including the type, number, state of registration, original date of issue, expiration date, and practice status in the state.
Provide your DEA, DPS, and other CDS numbers if applicable, including the original date of issue, expiration date, and practicing state.
Enter your National Provider Identifier and details about Medicare and Medicaid participation.
If applicable, include your Educational Council of Foreign Medical Graduates (ECFMG) number and issue date.
In the Professional/Specialty Information section, detail your primary and secondary specialties, board certifications, and intentions regarding board certification if not already board certified.
Provide a work history including your current and previous employers, addresses, and reasons for discontinuance. Explain any gaps in employment longer than six months.
If applicable, list hospital affiliations, types of privileges, and percentages of admissions.
Provide three peer references who have firsthand knowledge of your abilities, are not partners in your practice, and are not relatives.
Include information regarding your professional liability insurance coverage, including the name of the carrier, policy number, effective dates, and amount of coverage.
List names of colleagues providing regular coverage, their specialties, and full names of all partners in your practice if applicable.

Once all sections of the form are completed, review the information for accuracy and completeness. Attach any additional required documents or information as directed by the instructions within the form. Lastly, send the application to the carrier with whom you wish to become credentialed, ensuring that you meet all specified deadlines. Understanding each step and providing thorough and accurate information can streamline the credentialing process, facilitating your entrance into the Texas healthcare system.

Listed Questions and Answers

What is the Texas Standardized Credentialing Application (LHL234)?

The Texas Standardized Credentialing Application, known as LHL234, is a document created according to the Texas Insurance Code § 1452.052. It is designed for healthcare professionals who wish to become credentialed with insurance carriers in Texas. The form collects comprehensive professional and personal information to streamline the credentialing process.

Who needs to fill out the Texas Credentialing Application form?

Healthcare professionals, such as those in medical, dental, chiropractic practices, and other related fields looking to get credentialed with insurance providers in Texas, are required to fill out this form. This includes those who are applying for the first time, as well as professionals who are recredentialing.

What information do I need to provide in the application?

The application requires a range of information, divided into several sections:

Individual Information: Basic personal details, education, and work eligibility in the United States.
Education: Details on professional and post-graduate education, including any additional training.
Licenses and Certificates: Information on all state licenses, certifications, DEA, and DPS numbers, if applicable.
Professional/Specialty Information: Board certifications, specialties, and any intentions to take board exams.
Work History: A chronological list of employment, gaps in employment, and explanations for these gaps.
Hospital Affiliations: Details on hospital privileges and admissions.
References: Names and contact information for three peer references.
Professional Liability Insurance Coverage: Information on current and previous malpractice insurance.

Where should I send the completed application?

The completed application should be sent directly to the insurance carrier(s) with whom you wish to be credentialed. It's essential to verify the correct mailing or electronic submission process for each carrier as procedures may vary.

What happens if there are gaps in my work history?

For any gaps in employment that lasted more than six months, you must provide an explanation within the work history section of the form. It's crucial to be honest and provide as much detail as possible to avoid delays in the credentialing process.

Can I attach additional documents to the application?

Yes, the application provides opportunities to attach additional documents, such as Attachment A for other professional degrees, Attachment B for additional postgraduate training, and other relevant attachments for further work history and hospital affiliations. These attachments allow you to provide a comprehensive overview of your qualifications and experience.

Is there a section for including malpractice insurance information?

Yes, the application includes a section for detailing your professional liability insurance coverage. This area requires information about your current malpractice insurance carrier or if you are self-insured, policy numbers, effective dates, coverage amounts, and the type of coverage. Detailed information about any previous carriers, if applicable, must also be included.

Common mistakes

Filling out the Texas Credentialing Application form is a crucial step for healthcare professionals aiming to practice in Texas. However, this process is laden with pitfalls that can delay or compromise one’s credentialing status. Being aware of common mistakes can streamline this process, ensuring that the information provided is accurate and complete. Here are four common errors:

Providing Incomplete Information: One significant error is not filling out every required section of the application. Each question is designed to assess various aspects of an applicant’s credentials, background, and qualifications. Leaving sections blank or partially filled can result in delays, as the credentialing body may need to request additional information or clarification, slowing down the approval process.
Errors in Personal Information: Simple mistakes such as typos in names, incorrect Social Security numbers, or wrong contact details can lead to significant problems. These errors can not only delay the process but also risk the loss of crucial communication between the credentialing body and the applicant.
Not Verifying Licensure and Certification Details: Applicants must ensure that all licensure and certification information, including numbers, issuance dates, and expiration dates, are accurate and current. Failing to update this information or entering incorrect details can misrepresent an applicant's qualifications, potentially leading to denial of the application.
Failing to Explain Employment Gaps: The application requires a detailed work history, including explanations for any employment gaps longer than six months. Neglecting to provide these explanations, or providing insufficient details, can raise concerns about an applicant’s professional continuity, prompting further inquiry from the credentialing body.

To avoid these common mistakes, applicants should:

Review the entire application before starting, noting all required information.
Double-check personal and professional details for accuracy.
Update and verify all licensure and certification details.
Prepare concise yet comprehensive explanations for any significant employment gaps.

Taking these steps can significantly smooth the credentialing journey, minimizing the likelihood of delays or rejections, and paving the way for a successful practice in Texas.

Documents used along the form

Completing the Texas Credentialing Application form, a comprehensive document designed by the Texas Department of Insurance, is a critical step for healthcare providers looking to establish or continue their practice in Texas. However, to ensure a smooth credentialing process, several additional documents and forms often accompany the main application. Understanding these supplementary materials can help in creating a complete application package, thereby expediting the credentialing process.

Curriculum Vitae (CV): A detailed resume outlining the applicant’s education, training, work history, publications, and other professional activities. It provides a comprehensive look at the applicant’s professional background.
Proof of Professional Degrees: Copies of diplomas or certificates from the educational institutions attended by the applicant, confirming their qualifications.
Medical License: A copy of the current medical license in the state of Texas or other states where the applicant is licensed to practice, showing they are recognized as a medical professional.
Board Certification Documents: Proof of board certification or eligibility, showing that the applicant meets the specialty standards set by the medical community.
DEA (Drug Enforcement Administration) Certificate: A document verifying the applicant's eligibility to prescribe medications in the United States, indicating they are trusted with controlled substances.
Malpractice Insurance Certificate: Evidence of current malpractice insurance coverage, ensuring the applicant has liability protection.
Continuing Medical Education (CME) Credits: Documentation of completed continuing education required to maintain licensure and keep up-to-date with the latest medical knowledge and technologies.
Work History and Gap Explanation: An explanation of any gaps in employment, offering clarity on the applicant’s professional trajectory and ensuring there are no unaccounted periods.

Gathering these documents in conjunction with the Texas Credentialing Application can be time-consuming but is necessary to verify the qualifications and credentials of healthcare providers. Being thorough and providing a complete package not only demonstrates professionalism but also significantly facilitates the review process, ultimately benefiting patients by ensuring they receive care from fully vetted and competent professionals.

Similar forms

The Texas Credentialing Application form shares similarities with the Common Application used by undergraduate colleges and universities. Both forms collect comprehensive personal, educational, and historial information, intended to provide a complete profile of the applicant. While the Texas Credentialing Application focuses on medical professionals seeking to practice within a specific network or hospital, the Common Application serves students applying to multiple institutions for academic study. Each requires detailed education history, licensure (academic certifications for students), and personal identification details to assess eligibility and qualifications.

Another document resembling the Texas Credentialing Application is the Professional License Application used by various state boards for occupations such as accounting, engineering, and law. These applications gather extensive details about an individual's educational background, work history, and any professional licenses already obtained, similar to the data collected in the Texas form. The primary aim is to verify the applicant meets all criteria to practice a profession within a specific jurisdiction, ensuring they possess the necessary skills, knowledge, and ethical standards required for public practice.

The Employment Application, commonly used by employers in various industries, also shares similarities with the Texas Credentialing Application. Both forms require detailed personal information, employment history, educational background, and professional references. However, while the Employment Application is broad, applying to a wide range of job types and sectors, the Texas Credentialing Application is specialized, focusing solely on healthcare professionals looking to be credentialed by insurance carriers.

The Medical Residency Application, through platforms like the Electronic Residency Application Service (ERAS), draws parallels with the Texas Credentialing Application in its demand for extensive educational information, internships, residencies, and any specialties. Both are designed for the healthcare field, yet the residency application is tailored to recent medical graduates seeking training opportunities, whereas the Texas form is for seasoned professionals seeking credentialing for practice.

The Hospital Privileges Application, required for doctors seeking to admit and treat patients in hospitals, closely aligns with the section of the Texas Credentialing Application that pertains to hospital affiliations. Both documents assess a medical professional’s qualifications, work history, and specialties to determine their eligibility for practicing within a hospital setting, ensuring they meet specific standards of care.

The Visa Application is somewhat similar to the Texas Credentialing Application, particularly in sections requesting personal information, citizenship status, and eligibility to work in the United States. Although serving vastly different purposes—one for credentialing within the healthcare industry and the other for entry and residence in a country—both require thorough background information to assess eligibility and compliance with regulatory standards.

The Mortgage Application process also mirrors aspects of the Texas Credentialing Application, especially in its requirement for detailed personal, financial, and occupational information. While the focus is on assessing financial credibility and the ability to repay a loan rather than professional qualifications, both processes demand a high level of detail and accuracy in the information provided, impacting the approval outcome.

Similarly, the Life Insurance Application process requires comprehensive personal and professional details, akin to sections of the Texas Credentialing Application. Applicants must disclose in-depth health, occupational, and sometimes lifestyle information to assess risk and eligibility. Both forms require stringent verification of details provided to ensure accuracy and integrity in the approval process.

Lastly, the Grant Application for research or project funding shares the detailed project descriptions, personal and organizational qualifications, and historical outcomes found in the Texas Credentialing Application. Although one focuses on securing financial backing for projects and the other on professional credentialing, both require demonstrating qualifications, experience, and the potential to meet specified standards or objectives.

Dos and Don'ts

Filling out the Texas Credentialing Application form is a critical step for healthcare professionals seeking to practice within the state. This document, which plays a vital role in the credentialing process, necessitates careful attention to detail. Let's explore some essential dos and don'ts that applicants should keep in mind to ensure a smooth application process.

Do's:

Review the entire application before starting: Understanding the scope and requirements of the application can help prevent any missed sections and ensure you have all the necessary information on hand.
Complete every section accurately: Provide precise information for each question, adhering to the specified format, especially for dates (MM/DD/YYYY) and contact details.
Use official documents for reference: When filling out personal data, educational history, licenses, certifications, and work history, refer to official documents to prevent any discrepancies.
Disclose all relevant history: It includes your educational background, licenses in all states (active and inactive), and a comprehensive work history. Transparency is key to avoiding delays in your credentialing process.
Proofread the application: Before submission, thoroughly review the application to check for any errors or omissions. Accurate and complete information is crucial for a smooth verification process.

Don'ts:

Leave sections blank: If a section does not apply, indicate with “N/A” or “None,” rather than leaving it empty, to confirm you didn’t overlook it.
Assume one size fits all: The credentialing process can vary by carrier. Always use the most current form specific to the Texas Department of Insurance for credentialing to ensure compliance.
Use informal language or abbreviations: Stick to professional, clear language and avoid using jargon or abbreviations that might not be universally understood.
Rush through the application: Take your time to fill out the form correctly. Mistakes or inaccuracies can cause delays or even rejection of your application.
Forget to sign and date: An unsigned or undated application is incomplete. Ensure all required signatures are in place and the form is dated before submission.

By following these guidelines, healthcare professionals can navigate the Texas Credentialing Application process more efficiently, laying a strong foundation for their practice in Texas. Remember, the credentialing process is crucial for both provider verification and patient safety, making attention to detail on the application of utmost importance.

Misconceptions

When medical and healthcare professionals approach the Texas Credentialing Application form, there are often misconceptions that can muddy the process. Here are eight common ones, along with explanations to set the record straight:

Only Texas residents can apply: Some believe this application is limited to Texas residents. In reality, any professional who meets the qualifications and wants to practice in Texas, regardless of their residency, can apply.
The process is quick: Many think that credentialing is a fast process. However, due to the thorough checks on education, work history, and professional standing, the process can take several months.
All sections apply to all applicants: Not every section of the application will apply to each applicant. For example, the section on military service is only relevant if you've served in the military. Paying attention to relevant sections will save time and effort.
Professional liability insurance details aren’t critical: Some applicants might think that the specifics of their professional liability insurance aren’t crucial. Yet, accurate and detailed information is vital for the credentialing process.
Dates of education and employment can be approximated: Accuracy is key. Even small inaccuracies in dates of education or employment can raise questions about an application's validity.
You need to be board certified in your primary specialty to be eligible: While board certification is important and can be a testament to your skill and dedication, it’s possible to apply for credentialing without it, especially if certification is pending or you are eligible for examination.
Past employment gaps aren’t significant: Any gap in employment over six months needs to be explained. These gaps can be due to various reasons such as further education, family leave, or personal issues, but they must be documented.
References from any medical professional are acceptable: References should be from peers in the same field or specialty, who are neither partners in your group practice nor related to you. This ensures an unbiased assessment of your professional competencies.

Understanding these misconceptions and approaching the Texas Credentialing Application with accurate and complete information will help streamline the credentialing process, bringing healthcare professionals one step closer to practicing in Texas.

Key takeaways

Understanding the Texas Credentialing Application form is essential for healthcare providers in the state of Texas who wish to become credentialed with insurance carriers. Here are seven key takeaways to navigate this process effectively:

The Texas Credentialing Application, referred to as LHL234 Rev. 01/07, is mandated by Texas Insurance Code § 1452.052 and is promulgated by the Texas Department of Insurance. It is the standardized form used across the state for credentialing purposes.
Applicants must submit the completed form to the insurance carrier with whom they wish to be credentialed. This implies that separate submissions may be necessary if seeking credentialing with multiple carriers.
The form requires detailed personal and professional information. This spans basic personal details, educational backgrounds (including postgraduate education), professional degrees, and licensure in various states. Such comprehensive data supports thorough vetting by insurers.
License and certification details are paramount. This includes all current and previous licenses in any state, DEA, and DPS numbers, as well as board certification information. Being meticulous and accurate in this section is crucial for a positive outcome.
Work history is closely scrutinized. Applicants must provide a detailed chronological work history, including explanations for any employment gaps exceeding six months. This transparency helps insurers assess reliability and continuity in practice.
Hospital affiliations and admitting arrangements are necessary for insurers to understand the applicant's clinical capabilities and where they deliver care. Details about privileging status, types of privileges, and percentage of admissions to each hospital are required.
Professional liability insurance information and call coverage arrangements must be disclosed. This includes current and previous malpractice insurance carriers, policy numbers, coverage amounts, and the type of coverage (occurrence or claims-made). Details about colleagues providing call coverage should also be included.

Overall, the Texas Credentialing Application form requires thorough and accurate information across several aspects of a healthcare provider’s professional life. Attention to detail and complete disclosures are vital for a successful credentialing process with insurance carriers.

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