ESRD Provider Changes

Please select the corresponding link below to access the checklist with all form neccessary for Provider Changes. Please submit completed packets for consideration.  

Please submit Initial Applications and Documentation to:
LDH/HSS
Attention: Margaret Huguet, RN
P.O. Box 3767
Baton Rouge, LA 70821

 

Relocation

Adding Modalities/Services

Adding/Deleting Stations

Expansion or Structural Renovations

Name Change

Key Personnel Change Form

Change of Ownership

MD Waiver