A RHC that is Licensed as an Outpatient Department of the Hospital, Certified as an Independent RHC but Provider Based to the Hospital

The information and forms in this packet are designed to assist providers in submitting the information for the initial licensing of a Rural Health Clinic that is licensed as an offsite campus outpatient department of a hospital but certified independently as a Rural Health Clinic.  Please mail the packet to the Department of Health and Hospitals, Health Standards Section, P. O. Box 3767, Baton Rouge, LA 70821. Any fees associated with the application should be sent to LDH-Licensing, P.O. Box 62949, New Orleans, LA 70162-2949.

 Licensing

• HSS-RH-01 Rural Health Clinic License Application

 CMS Forms

• CMS 29
• CMS 1561A
• CMS 855A (may be required)
• Office of Civil Rights Clearance

 Hospital Offsite Campus Rural Health Clinic Addition Packet (use option #3)

 Accreditation Organizations Approved for Rural Health Clinics

 Other Agencies:

• Office of State Fire Marshal Inspections
  • Louisiana Administrative Code 55:V:103 - As of July 1, 2004, the plans and specifications for every structure built or remodeled in the state of Louisiana must be drawn in accordance with the requirements of the specified edition of the Life and Safety Code (excluding Chapter 5 and all TIA's) of the National Fire Protection Association.
    • You can contact the Office of State Fire Marshal Code Enforcement and Building Safety at 8181 Independence Blvd, Baton Rouge, LA 70806, 800-256-5452 or 225-925-4414. You can also view information, instructions and forms online.
  • Most licensing actions require a walk through inspection by the Office of State Fire Marshal. You can contact the Health Care Division of the Office of State Fire Marshal at 800-256-5452 or 225-925-4270. You can also obtain information and instructions online.
• Office of Public Health Inspections
  • Most licensing actions require a walk through inspection by the Office of Public Health. You can contact Aimee Jaffurs with the Building & Premises Program of the Office of Public Health at 225-342-7523 to obtain information on scheduling your onsite public health inspection. You can also reach her by email at Aimee.Jaffurs@la.gov.
  • Please remember that the inspection approval report must indicate the correct name & location of the hospital and/or off-site campus. In addition, the report must indicate the areas being inspected.
• Louisiana Board of Pharmacy
  • To arrange for your Controlled Dangerous Substance license, call 225-925-6496.
• Drug Enforcement Agency
• CLIA