Nurse Staffing Agency (NSA) Initial Licensure Requirement

Initial License Application Checklist for Providers

 

 Initial Licensing Application Packet shall include:

1. Completed license application form.

2. non-refundable licensing fee: the Payment Procedure has changed please follow the link for instructions.

3. a copy of verification of current active business with the Secretary of State, or equivalent state business registry, which  references the current registered agent; 

4. a copy of the organizational chart of the NSA, including the names and addresses of the person or persons under whose management or supervision the NSA will be operated;

5. a statement detailing the experience and qualifications of the applicant to operate an NSA;

6. a statement of financial solvency, comprised of the following:

         a. a line of credit issued from a federally insured, licensed lending institution in the amount of at least $25,000 that is:

                i. current and in effect at the time of submission of the application for licensure; and

                ii. issued to and in the name of the applicant shown on the application for licensure;

        b. general and professional liability insurance in an amount sufficient to provide coverage in accordance with the total amount recoverable for all malpractice claims as indicated in R.S. 40:1231.2, or current law; and

        c. worker’s compensation insurance that is in compliance with the Louisiana Workers' Compensation Law, R.S.23:1020.1 et seq., or current law, with a minimum coverage in the amount of $1,000,000 that is current and in effect at the time of submission of the license application;

7. proof that the LDH, HSS is specifically identified as the certificate holder on any policies and any certificates of insurance  issued as proof of insurance by the insurer or producer (agent);

8.  a copy of a statewide criminal background check including sex offender registry status, on all applicant(s), owner(s) with 5 percent or more ownership interest, and administrator/director, for any state lived in within the last five years;

9. a statement of the days and hours of operation; and

10. Disclosure of Ownership form