Forms for Providers who are SELF-INSURED

SELF-INSUred

Forms for Healthcare Professionals with Self Insurance

PCF06	Application for Healthcare Professional
PCF06R	Renewal Application for Healthcare Professional

Forms for Hospitals with Self Insurance

PCF07

Forms for Nursing Homes and Assisted Living Facilities with Self Insurance

PCF08

Forms for FTEs, Locum Tenens, Clinics, ER Groups and Surgical Centers with Self Insurance

PCF16

Additional Forms As Needed for Any of the Above Self Insured Health Care Providers

PCF09	Application for Corporations
PCF11	Questionnaire for Those With Limited or No Practice in Louisiana
PCF12	Part Time Questionnaire
PCF13	Pledge Agreement
PCF14	Application for Management Companies