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Pre-Application for Medical Staff and Advanced Practice Professionals at LCMC Health

Thank you for your interest in becoming a member of the Medical Staff/ Allied Health Professional (AHP) Staff at LCMC Health. Please complete this form to receive an application packet.

To be eligible to join our medical staff/AHP:

  • You must have a current unrestricted license or application pending in Louisiana, a current Controlled Substance License and Federal Drug Enforcement Agency (DEA) number (if required by your specialty). If you do not currently have a Louisiana license, you must hold an unrestricted license in another state and have an application pending with your respected board in the state of Louisiana.
  • In addition to the qualifications set forth above, appointment to and maintenance of Medical Staff/ AHP membership shall be subject to and conditioned upon such other qualifications and requirements as may be expressed or implied elsewhere in Medical Staff Bylaws, Rules & Regulations, and medical staff policies as applicable.
Name*
Office Address*
Are you a US citizen?*
Is the provider board-certified?*
Are you interested in requesting moderate sedation privileges?
Provider's anticipated start date*
--- Please note --- Processing an application for medical staff privileges can take an average of 90-120 days. Please keep this in mind especially if the provider is pending issuance of a Louisiana medical license. The anticipated start date is not guaranteed and may be adjusted to accommodate processing and/or Committee and Board approvals.

Please answer each of the following questions. If the answer to any question is "Yes," please provide a full explanation with details in a separate document and upload below.

Have you been disciplined or reprimanded at any hospital, health care facility, or managed care organization due to your clinical competence or professional conduct?*
Has your employment, Medical Staff/Allied Health Membership, or privileges ever been relinquished, withdrawn, suspended, reduced, revoked, denied, investigated, challenged, not renewed, or subject to probationary or other conditions at any hospital, health care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?*
Are there presently any proceedings or investigations taking place at any hospital, health care facility, or managed care organization relating to your clinical competence or professional conduct?*
Have you ever been the subject of focused individual monitoring relating to your clinical competence or professional conduct at any hospital, health care facility, or managed care organization?*
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 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 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?*

Licensure

Have any investigations or disciplinary actions ever been initiated by any state licensure agency or are there any currently pending?*
Has your license to practice in any state ever been relinquished, suspended, modified, restricted, denied, challenged, or terminated, whether voluntarily or involuntarily?*
Have you ever been asked to surrender your license in any state?*
Have you ever been reprimanded or otherwise sanctioned by, or had conditions placed on your license by, any licensure agency?*
Are there currently any restrictions on your CDS/DEA registration?*
Please explain:*
No File Chosen
File uploads may not work on some mobile devices.
Any misrepresentation, misstatement, or omission during the application process, whether intentional or not, is cause for the immediate cessation of the processing of this application and no further processing shall occur. Upon subsequent discovery of such misrepresentation, misstatement, or omission, the entity to which I am applying may deem any relationship they have with me to be automatically relinquished, including but not limited to medical staff/ AHP appointment, clinical privileges, participating provider status or contracts. In either situation, there shall be no entitlement to any hearing or appeal rights that are contained in the entities bylaws, policies, or contracts. I request an application for appointment to the medical staff.*
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Date*

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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