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Request for Provider Application Form

Our Governing Board, as recommended by the Medical Staff, has adopted requirements for application, some of which are listed below. Please know that these are baseline standards.  Our Credentials Committee will conduct a full review of all completed applications prior to making a recommendation to the Board.  An application will be released if you meet appointment criteria.  If you have any questions, please contact the UMCNO Medical Staff Office at 504-702-4387 or MDStaffAdminMCL@lcmchealth.org.

Name*
Medical/Allied Health staff category requested*
You must have an affiliation with one of the 3 medical schools below to join UMC's medical staff or requesting to join as telemedicine or an advanced practice professional. Please select below.*
Have you successfully completed an accredited residency training program in the specialty in which you seek clinical privileges; or for Advanced Practice Professional Staff have you completed such advanced training as required by the State licensing board? *
Do you have a current unrestricted license or application pending in Louisiana for the discipline in which you are seeking membership and/or privileges?*
Have you ever been the subject of an investigation by any private, federal, or state agency concerning your participation in any private, federal, or state health insurance program?*
Have you ever been suspended, sanctioned, excluded, or otherwise precluded from participating in Medicare, Medicaid, or any other federal, state or private health insurance program?*
Have you ever been convicted of, or pled guilty or no contest to, any felony, or any misdemeanor relating to the practice of your profession, other health care-related matters, third-party reimbursement, violence, or controlled substances violations?*
Has your employment, Medical Staff/Allied Health membership, or privileges ever been relinquished, withdrawn, suspended, reduced, revoked, denied, investigated, challenged, not renewed, or subject to probationary or other conditions at any hospital, health care facility, or managed care organization, whether voluntarily or involuntarily due to these reasons? This will include resignation during an investigation.*
Have never resigned Medical Staff appointment or relinquished privileges during a Medical Staff investigation or in exchange for not conducting such an investigation*
Use your mouse or finger to draw your signature above

If you are you applying to multiple LCMC Health facilities, please be advised that you must complete a pre-application for each facility at their independent website.

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