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PCF Surcharge Application Forms

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Ken Schnauder, Executive Director
PCF Toll Free: 1.866.469.9555
PCF Main: 225.342.5200
Mailing Address:
P.O. Box 3718
Baton Rouge, Louisiana 70821
Physical Address:
Iberville Building
627 North Fourth Street
Suite 2-300
Baton Rouge, Louisiana 70802
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Click on the application name to view/print any application.

A signed application is needed. Please print out the document, sign it and submit it to our office.

PRIMARY INSURANCE

Forms for MDs & Adv​anced RNs with Primary Insurance

PCF01

Application for MDs & Advanced RNs

PCF01R

Renewal Application for MDs & Advanced RNs

PCF10

Procedure Questionnaire for those with "minor" or "major" surgery designation

Forms for Dentists with Primary Insurance

PCF02

Application for Dentists Oral Surgeons

PCF02R

Renewal Application for Dentists Oral Surgeons

Forms for Hospitals and Nursing Homes with Primary Insurance

PCF03

Application for Hospitals and Nursing Homes

PCF03R

Renewal Application for Hospitals and Nursing Homes

Forms for Non-MDs with Primary Insurance (Chiropractors, Optometrists, Pharmacists, Physical Therapists, Psychologists, etc.)

PCF04

Application for Non-MDs with Primary Insurance -- Chiropractors, Optometrists, Pharmacists, Physical Therapists, Psychologists, etc.

PCF04R

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

PCF05

Application for FTEs, Locum Tenens, Clinics, ER Groups and Surgical Centers

PCF05R

Renewal Application for FTEs, Locum Tenens, Clinics, ER Groups and Surgical Centers

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

PCF09

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

PCF06

Application for Healthcare Professional

PCF06R

Renewal Application for Healthcare Professional

Forms for Hospitals with Self Insurance

PCF07

Institutional Health Care Provider Application

Forms for Nursing Homes and Assisted Living Facilities with Self Insurance

PCF08

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

PCF09

Application for Corporations

PCF11

Questionnaire for those w/limited or no practice in LA

PCF12

Part Time Questionnaire

PCF13

Pledge Agreement

PCF14

Application for Management Companies