Ken Schnauder, Executive Director

Tel: (225) 342-5312
Fax: (225) 342-5318
Email: Ken.Schnauder@la.gov


1-866-469-9555
225-342-5200

Mailing Address:
P.O. Box 3718
Baton Rouge, Louisiana 70821

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Applications
Click on the application name to view/print any application.
ALL NEW PDF APPLICATIONS
A signed application is needed. Please print out the document, sign it and submit it to our office.
PRIMARY INSURANCE
Forms for MDs & Advanced RNs with Primary Insurance
PCF1 Application for MDs & Advanced RNs
PCF1R Renewal Application for MDs & Advanced RNs
PCF10 Procedure Questionnaire for those with "minor" or "major" surgery designation

Forms for Dentists with Primary Insurance
PCF2 Application for Dentists Oral Surgeons
PCF2R Renewal Application for Dentists Oral Surgeons
Forms for Hospitals and Nursing Homes with Primary Insurance
PCF3 Application for Hospitals and Nursing Homes
PCF3R Renewal Application for Hospitals and Nursing Homes
Forms for Non-MDs with Primary Insurance (Chiropractors, Optometrists, Pharmacists, Physical Therapists, Psychologists, etc. )
PCF4 Application for Non-MDs with Primary Insurance -- Chiropractors, Optometrists, Pharmacists, Physical Therapists, Psychologists, etc.
PCF4R Renewal Application for Non-MDs with Primary Insurance -- Chiropractors, Optometrists, Pharmacists, Physical Therapists, Psychologists, etc.
Forms for FTEs, Locum Tenens, Clinics, ER Groups and Surgical Centers with Primary Insurance
PCF5 Application for FTEs, Locum Tenens, Clinics, ER Groups and Surgical Centers
PCF5R Renewal Application for FTEs, Locum Tenens, Clinics, ER Groups and Surgical Centers
Additional Forms As Needed for Any of the Above Health Care Providers
PCF9 Application for Corporations
PCF11 Questionnaire for those w/limited or no practice in LA
PCF12 Part Time Questionnaire
PCF14 Application for Management Companies
SELF-INSURANCE
Forms for Healthcare Professionals with Self Insurance
PCF6 Application for Healthcare Professional
PCF6R Renewal Application for Healthcare Professional
Forms for Hospitals with Self Insurance
PCF7 Institutional Health Care Provider Application
Forms for Nursing Homes and Assisted Living Facilities with Self Insurance
PCF8 Nursing Home and Assisted Living Facility Application
Forms for FTEs, Locum Tenens, Clinics, ER Groups and Surgical Centers with Self Insurance
PCF16 Application for FTEs, Locum Tenens, Clinics, ER Groups and Surgical Centers
Additional Forms As Needed for Any of the Above Health Care Providers
PCF9 Application for Corporations
PCF11 Questionnaire for those w/limited or no practice in LA
PCF12 Part Time Questionnaire
PCF13 Pledge Agreement for Self Insured Providers
PCF14 Application for Management Companies
Sample Letter of Credit