Office of Group Benefits

Office of Group Benefits

OFFICE OF GROUP BENEFITS

PROVIDER CREDENTIALING APPLICATION

INSTRUCTIONS
Please type or print in ink when completing this form. If you need more space or have more than two locations, attach additional sheets and reference the question being answered. Complete an application for each provider under your tax identification number. Additional copies can be printed from OGB’s website (
** All applicable sections must be completed in their entirety. **

Section A

CONTRACT INFORMATION
Office/Facility Name/Group Name / Tax ID / Office/FacilityNPI #
Name to which Tax ID number is registered with the IRS (Important: Must match the name given on the enclosed W-9 form)
DBA (Doing business as name, if applicable)
Street Address (Physical address required) / City / State / Zip Code
Phone Number / Fax Number / Name of Contract Contact & E-mail Address
OFFICE/FACILITY INFORMATION
Street Address / City / State / Zip Code
Phone Number / Fax Number / E-Mail / Name Of Contact Person
BILLING INFORMATION
Address(For Payments & EOB’s) / City / State / Zip Code
Phone Number / Fax Number / E-Mail / Name Of Contact Person
CORRESPONDENCE INFORMATION
Address(For Letters) / City / State / Zip Code
Phone Number / Fax Number / E-Mail / Name Of Contact Person / Fax Number / E-Mail / Name Of Contact Person
INDIVIDUAL PROVIDER(S) INFORMATION
Please copy this form if additional providers need to be listed
Provider Last Name / First / Middle
Individual Provider NPI # / Date of Birth (mm/dd/yyyy)
/ / / Gender
Male Female
PRIMARY PRACTICE LOCATION
Street Address (Physical Address) / City / State / Zip Code
Phone Number / Fax Number / Name Of Contact Person & E-Mail
Specialty Of Practice: / Primary Specialty Secondary Specialty
SECONDARY PRACTICE LOCATION
Street Address (Physical Address) / City / State / Zip Code
Phone Number / Fax Number / Name & Title Of Office Manager
Specialty Practice: / Primary Specialty Secondary Specialty
Billing Address (Address To Which You Want Payments Sent) / City / STATE / ZIP CODE
Phone Number / Fax Number / Billing E-Mail / Name & Title Of Contact
For Any Additional Practice Locations,
Please Attach A Separate Page With The Above Information
SPECIALTY
PLEASE DENOTE PRIMARY AND SECONDARY SPECIALTY (as applicable).
PROVIDER MUST BE BOARD CERTIFIED OR BOARD ELIGIBLE IN THE SPECIALTIES SELECTED.
Prim Sec Specialty / Prim Sec Specialty / Prim Sec Specialty
Allergy/Asthma/Immunology
Anesthesiology
Ambulatory Surgical Center
Audiologist
Colon/Rectal Surgery
Cardiology
Cardiovascular &Thoracic Surgical
Chiropractor
Dermatology
Diabetic Educator
Dialysis
DiagnosticImagingCenter
Durable Medical Equipment
Emergency Medicine
Endocrinology
Otorhinolaryngology (ENT)
Family Practice
Gastroenterology
General Surgery
Geriatric Medicine / Hyperbaric Medicine
Hematology
Head and Neck Surgery
Hospital
Infectious Disease
Internal Medicine
Infusion Therapy
Laboratory Services (Facility)
LithotripsyCenter
LTAC Facility
Mastology
Microvascular/Hand Surgery
Neonatology
Nephrology
Neurosurgery
Neurology
Obstetrics/Gynecology
Optometry
Oncology
Ophthalmology / Oral/Maxillofacial Surgery
Orthopedics
Pain Management
Pathology (professional)
Pediatrics
Perfusionist
Pediatric Surgery
Physical Medicine Physician
Phys Medicine OT/PT/Rehab
Plastic Surgery
Podiatry
Pulmonology
Radiology (professional)
Radiation Oncology
RehabilitationHospital
Rheumatology
Somnologist
Speech Therapy
Urgent CareCenter
Urology
PROFESSIONAL LICENSES & REGISTRATION
Professional Licenses / License Number / Date Obtained / Expiration Date
State Medical License
Federal DEA Reg Number
State CDS License Number
Medicare Provider Number
BOARD CERTIFICATION
(as recognized by American Board of Medical Specialties)
(Please attach a copy of current certification(s)
Primary Specialty Board (ABMS) / Date Certified / Date Re-certified / Status/Exp. Date
Secondary Specialty Board (ABMS) / Date Certified / Date Re-certified / Status/Exp. Date
Please indicate below if you are currently pursuing any board certification. A copy of your board eligibility letter, documentation, or formal specialty training must be included in order to be listed in the directory under the specified specialty.
______
Board Name Termination Date

Section B

PROFESSIONAL LIABILITY INSURANCE COVERAGE
**PLEASE ATTACH A COPY OF THE CERTIFICATE OF INSURANCE**
Name Of Carrier / Liability Insurance Amounts / Policy Number / Term Date
Individual Coverage
Yes_____ No _____ / Policy Holder / Group Coverage
Yes ____ No ____ / Policy Holder
CURRENT HOSPITAL AFFILIATION (s)
List all hospitals at which you currently have admitting privileges or provide roster
Hospital / Location/Address / Type Of Privileges / Effective Date - Mo/Yr

Section C

REQUIRED ATTACHMENTS
OGB Health Plan Signed ContractFederal DEA Certificate
Current W-9 Form (Tax ID)State CDS Certificate
Application (For Each Provider)Certificate of Liability Insurance
State Medical LicenseDocumentation of Board Certification & Eligibility
Completed credentialing applications, attachments, and signed contracts should be mailed to:
Office Of Group Benefits
ATTN: ProviderServices
P. O. Box 44036
Baton Rouge, La 70804
I verify that the above information is accurate and that I have legal authority to modify the above information under the said Tax Identification Number. I acknowledge that the information on this form will affect the receipt address of future payments, notification of physical location to members, and other uses of this information by OGB. I understand that any material mis-statements or omissions from this form may constitute cause for denial of my application if requesting network participation.
______
NAME (Please Print) / ______
SIGNATURE / ______DATE

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OGB Rev: 01/10/11