Provider Credentialing

NLPHO does not discriminate or base credentialing decisions on an applicant's race, ethnicity or language.

DOCUMENTS FOR CREDENTIALING

• Letter for Initial Application
  
• Eligibility for Participation Form
  
• Louisiana Standardized Credentialing Application form
• Provider Professional Services Agreement
• Code of Conduct
• Provider Attestation
• Aetna & Coventry Medicare Advantage Enrollment Form
• Dignity Health Plan Enrollment Form
• Peoples Health Medicare Advantage Enrollment Form
• Louisiana Healthcare Connections Enrollment Form
• Nurse Practitioner Collaborative Practice Agreement
• Physician Assistant Notice of Intent to Practice
• W-9 form
• Facility Application

PROVIDER APPLICATION

Please forward a completed Eligibility for Participation Form to Jan Tidwell, CPCS at jan.tidwell@fmolhs.org. If eligible, Jan will contact you regarding submission of your application and appropriate supporting documents and agreements.

HOSPITAL / ANCILLARY / DME APPLICATION

Please forward the Facility Application to Jan Tidwell, CPCS at jan.tidwell@fmolhs.org.