Rural Health Clinics

Initial Licensure

There are 3 ways that a Rural Health Clinic can be licensed and certified in Louisiana.

License Renewal 

1. A renewal letter will be mailed to the provider from the Health Standards Section approximately 80 days in advance of the license expiration date.
2. Items that shall be submitted to the Health Standards Section for a license renewal:
   • Renewal Application
   • Licensing fee
   • Copy of the current Fire Marshall Inspection
   • Copy of the current Health Inspection Report
3. Once all requirements have been met, a new license will be mailed to the provider on the 20th or 21st  of the month before the current license expires.

Doing Business As (DBA) Name Change

The information and forms in this packet are designed to assist providers in completing information to change the "DBA" name of the Rural Health Clinic.  Please DON'T use this packet if the corporate/legal entity name changes.

If the name change occurs in an RHC that is licensed as an offsite campus of a hospital, you will also need to submit a Hospital DBA Name Change Packet to the Hospital Program Manager assigned to your hospital.

Legal Entity Name Change

The information and forms in this packet are designed to assist providers in completing information to change the "legal entity" name of the Rural Health Clinic. This should be identical to the legal name reported to the IRS. Please DON'T use this packet if you are only changing the DBA (doing business as) name of the RHC.

If the legal entity name change occurs in an RHC that is licensed as an offsite campus of a hospital you will also need to submit a Hospital Legal Entity Name Change Packet to the Hospital Program Manager assigned to your hospital.

Address Change

This packet is designed to assist providers in completing information to change the corporate legal entity address. This packet is not to be used for a change of ownership, changes in corporate names, or relocations of any Rural Health Clinic campuses.

RHC Key Personnel Changes

This packet is designed to assist the provider in submitting the required information, forms and fees for a Rural Health Clinic undergoing changes in key personnel (Medical Director, physicians, mid-level practitioners and administrators).

Important: All official correspondence from Health Standards and CMS will go to the email address of the administrator that is currently on file with Health Standards. Please be sure to keep this current through the use of this packet.

Change of Ownership Information

Providers must complete this document when they have a change in their ownership structure. This document would be used for both a change of ownership (CHOW) as defined by state and/or federal regulations, or a change of ownership information (CHOI) that does not meet the state and/or federal regulations CHOW definition.

For Health Standards to make a CHOW/CHOI determination, all providers must submit the following documents:

1. Letter of Intent (including d/b/a (doing business as) and entity name of the previous and the new owner, the effective date of change of ownership, address and phone number).
2. A diagram showing the ownership structure “before” and “after” the change
3. Copy of the executed legal transaction documents (Bill of Sale, lease, etc.)
4. CHOW/CHOI License Application
5. Change of Ownership Application
6. 855A/B approval letter for the following Medicare Certified providers: Home Health, hospice, hospitals, RHCs, ASCs, ESRDs, portable x-ray, community mental health, CORF, Nursing Facilities, and OPT.

Note: If this action is a CHOI, the documents above are the only documents you need to submit, however the Department may, at its discretion, request additional documentation in support of the CHOI. If so, you will be contacted for any of said additional documents. There is no fee for a CHOI. 

If this action is a CHOW, the following are also needed:

1. Does your facility have a CLIA Certificate? If yes, you may also be required to complete a CHOW for CLIA.
2. Licensing Fee: Click here for the link for the Health Standards Fee Schedule

Note: The fee for a CHOW is usually the same as a license renewal unless the facility is making additional changes. For providers completing an acquisition/merger, please contact the program desk for assistance.

Additional Documents Required

1. *License Application Emergency Preparedness Addendum form (Medicare Certified RHC)
2. *Form CMS-1561A Health Insurance Benefit Agreement (Medicare Certified RHC)
3. *Electronic verification from the Office of Civil Rights (OCR) of successful submission. (Medicare Certified RHC) Click here for the form
4. OSFM inspection
5. OPH inspection
6. IRS Information Showing Legal Name & EIN

For all other Change of Ownership Information, please contact the HSS Ownership Group

Service Actions

The information and forms in this packet are designed to assist providers in notifying Health Standards of service actions at Rural Health Clinics such as the following:

•  Adding services
•  Deleting services
•  Changing the space where services are provided
•  Altering and/or renaming rooms on the floor plan that is currently on file with this agency

If any of these changes occur in an RHC that is licensed as an offsite campus of a hospital, you will also need to submit a Hospital Service Change Packet to the Hospital Program Manager assigned to your hospital.

Closures

The instructions and forms in this packet are designed to assist providers in submitting the required information in order to terminate the license of an independently licensed Rural Health Clinic. If you want to terminate the license of a Rural Health Clinic that is licensed as an outpatient department of a hospital, please visit the Hospital web page.

Forms