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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 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 successfully completed an accredited residency training program in the specialty in which the applicant seeks clinical privileges; or for Advanced Practice Professional Staff have completed such advanced training as required by the State licensing board for such applicant*
Have current, valid professional liability insurance coverage in a form and in amounts determined by the Board *
Have never been convicted of Medicare, Medicaid, or other Federal or State governmental or private third-party payer fraud or program abuse, nor have been required to pay civil monetary penalties for the same*
Have never been, and not currently be, excluded or precluded from participation in Medicare, Medicaid, or other federal or state governmental health care program*
Have never been convicted of, or entered a plea of guilty or no contest, to any felony; or to any misdemeanor relating to controlled substances, illegal drugs, insurance or health care fraud or abuse, or violence *
Have never had Medical Staff appointment, clinical privileges, or status as a participating provider denied, revoked, or terminated by any health care facility or health plan for reasons related to clinical competence or professional conduct; *
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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