To assist LQ's Accounting Professionals with the preparation of various application, we have developed the following checklist. Providing a copy of each documents will expedite the processing timeframe.

1. A complete provider matrix
2. A current curriculum vitae
3. A current copy of the board certification
4. A current copy of the professional state license
5. A current copy of the state narcotic license (if applicable)
6. A current copy of the Federal DEA Certificate
7. Copy of Collaborative Agreement for all NPs and PAs
8. Copy of IRS documentation (Letter 147T, or 147C, Federal Deposit Coupon, ETPS, Letter CP575
9. W-9 Tax Identification Form
10. A current copy of liability and Malpractice insurance with minimal coverage amounts of 500,000.00 Or be a member of the Louisiana Compensation fund.
11. ECFMG Certificate (if applicable)
12. Banking Information (Please attach a copy of the voided check for the bank letter for EFT payments)
13. Copy of CLIA waiver certificate
14. History of Malpractice Claims

The credentialing process will not begin until all of the above documents/information is received.