Apply

PRINTABLE APPLICATIONS (PDF)

Information entered into PDF applications cannot be saved. You must print, sign, and return (by email, fax, or mail) the completed application to LSA.

• Individual application
• Allied health care professional application
• Entity application

QUESTIONNAIRES

If you perform any of these procedures, please submit the appropriate questionnaires with your application.

• Bariatric
• Chiropractic
• Cosmetic
• Infusion Therapy
• Nurse Midwife
• Pain Management
• Podiatry
• Prenatal
• Telemedicine

FORMS

HIPAA-HITECH Business Associate Agreement
An agreement required by federal law concerning policies and procedures to assure the confidentiality of patient health information.