Rural Health Clinic 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). Please be sure to mail the entire packet to: Department of Health and Hospitals, Health Standards Section, P.O. Box 3767, Baton Rouge, LA 70821.

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.

HSS-RH-01 Rural Health Clinic License Application

HSS-ALL-37 Key Personnel Change Form