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Pre-Application Form

Name*
Birthdate*
Office Address*
Residential Address*
2. Do you plan to establish, or have you established an office on the Westbank of Jefferson, Orleans, Plaquemines, or St. Charles Parishes?
Hospital, address, and appointment dates
7. Have you ever had any past adverse licensure action against you by any state or federal licensing board?
8. Do you have any of the following?*
8. Do you have any of the following?
  Yes No
Any felony conviction?
Conviction of any Medicare, Medicaid, or insurance fraud or exclusion from such programs?
Any conviction of felony or misdemeanor related to professional practice, reimbursement or controlled substance violations?
9. Have your medical staff privileges or appointments ever been modified, denied, revoked or terminated for reasons related to professional competency or conduct or during an investigation into competency or conduct?
10. What category do you intend to apply for?*

Upload Documents

The Pre-Application Form MUST be returned with copies of the following documents:

Current license(s) to practice medicine*
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Narcotics registration certificate*
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Professional liability insurance policy and certificate of coverage from insurance carrier*
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Medical school diploma or ECFMG certificate *
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Evidence of board certification status or satisfactory completion of ABMS approved residency*
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A curriculum vitae*
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A current photograph*
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A case log – to include number of procedures performed in the past two (2) years and associated outcomes*
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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 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
I recognize that membership on the Medical/Dental Staff of this Hospital is contingent upon professional competence and ethical practice in keeping with the qualifications, standards and requirements set forth in the Medical/Dental Staff Bylaws, Rules and Regulations. I further recognize that the Medical/Dental Staff of this Hospital must periodically reevaluate my professional competence and qualifications and make appropriate recommendations to the Governing Body. Accordingly, it may be necessary for the Medical Staff to request of other persons and institutions, including medical schools, hospitals, medical societies, professional liability insurance carriers, individual practitioners and other appropriate sources information regarding my qualifications and performance. Additionally, I understand that the Hospital and Medical/Dental Staff may receive similar requests, from other legitimately interested organizations and institutions, as an applicant and/or member of this Medical/Dental Staff. I understand that all evaluations, inquiries, and responses to inquiries regarding my professional competence and qualifications shall be carried out in a professional and ethical manner, with due regard for appropriate confidentiality of the information at issue.*
I also recognize that I will be afforded the fair hearing procedure prescribed by the Medical/Dental Staff Bylaws in the event that action on this application, or with respect to my privileges, is adverse. Recognizing these facts, I specifically agree and consent to the following: (1.) To appear if requested before Medical Staff officers, department and service chiefs, and Medical Staff Committees for interviews or inquiries regarding this application for reappointment. (2.) To assist, in every way possible, this Medical Staff and its representatives, in gathering the information necessary to determine my qualifications. In this regard, I recognize that I have the burden of resolving any reasonable doubts about my qualifications for staff membership and the requested privileges. (3.) To the dissemination of information including all Medical Staff and medical records pertaining to my professional qualifications between this Hospital and its Medical Staff and other persons, hospitals, medical staff, professional societies, training programs, professional associations, professional liability insurance companies, and licensing authorities in jurisdictions in which I have trained, resided, or practiced, for the present and continuing evaluation of my professional training, experience, character, conduct and judgment; (4.) To be bound by the terms of the Medical Staff and Hospital Bylaws in all matters relating to the consideration of this application, regardless of whether I am granted Medical Staff membership and the privileges sought. In this opportunity to review the Medical Staff Bylaws, Rules and Regulations, and any Hospital Bylaws or rules and policies which may pertain.*
I pledge to maintain an ethical practice, to provide for continuous care of all my patients, and to acknowledge and abide by any Medical Staff Bylaws requirements for release and immunity from civil liability. I further release from liability any persons or entities which request or provide information in furtherance of the above-described purposes, whether or not such release is specifically required by pertinent bylaws, to the fullest extent established by applicable statutes regulations and judicial decisions. I fully understand that any significant misstatement(s) in or omission from these applications will constitute cause for cessation of processing said application(s) for requested membership and medical privileges or cause for revocation of membership of privileges. I hereby affirm that the information furnished by me to the Medical Staff is true to the best of my knowledge and is furnished in good faith. I have received, read, and agree to abide by the Medical/Dental Staff Bylaws, Rules & Regulations and any other hospital policy that may be in effect from time to time.*
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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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