Louisiana Patient's Compensation Fund

Credentialing Request Form

Requested By

Fax / Email

Provider Requested

Use the provider details below to identify the health care provider this credentialing request is about.

Provider's Full Name

Address Line 1

Address Line 2

Address City, State, Zip Code

Certificates of enrollment can be obtained from the PCF website for current enrollment.

All requests for claim data are considered personal and confidential and cannot be released without signed authorization from the health care provider. The signed authorization must be attached prior to release of information.

In accordance with Act 306 of the 2004 Regular Session, the filing of a request for a medical review panel is not reportable. Therefore, this agency will only report claims known to have a suit or other documents filed in court or for which this agency has made a payment. See La. R.S. 40:1299.47.A.(1)(a).

Liability Provided

Excess to $100,000 primary coverage up to $400,000 plus unlimited related medical expenses per La. R.S. 40:1299.42. There is no aggregate with the PCF.

Type of Policy/Enrollment

Claims Made

Occurrence

Provider Specialty/Class

PCF rate manual dictates class and procedures applicable to class/specialty above.

PCF Coverage Period

From

Paid Claims Details and Claims History

None

See Attachment

Completed By

Signature

Date