Department of Health | State of Louisiana



Home and Community Based Services Provider (HCBS)Change of Geographical Address ChecklistName of Agency:____________________________________________?? 1. Submitted required documentation to Health Standards Section, Facility Need Review department. ? 2. Completed HCBS licensure application and documents requested below, mailed to Health Standards Section, P.O. Box 3767, Baton Rouge, Louisiana, 70821-3767;? 3. Submitted non-refundable licensing fee (see payment transmittal form for more information)? 4. Current approval letter of the architectural facility plans from the Office of the State Fire Marshal (Adult Day Care and Center Based Respite modules);? 5. Current on-site inspection report with approval for occupancy by the Office of the State Fire Marshal (Adult Day Care and Center Based Respite modules);? 6. Current health inspection report with approval of occupancy from the Office of Public Health (Adult Day Care and Center Based Respite modules);? 7. Proof of financial viability (with the new address listed), comprised of: a line of credit letter issued from a federally insured, licensed lending institution in the amount of at least $50,000. *For the purposes of an HCBS licensure, personal loans or bank balances of $50,000 or more do not meet this requirement.? No waiver of this requirement will be granted.certificate of general and professional liability insurance of at least $300,000. Certificate holder must state: Louisiana Department of Health, Health Standards Section, P. O. Box 3767, Baton Rouge, Louisiana 70821-3767; andcertificate of worker’s compensation insurance. Certificate holder must state: Louisiana Department of Health, Health Standards Section, P. O. Box 3767, Baton Rouge, Louisiana 70821-3767.? 8. Completed disclosure of ownership and control information form;? 9. Floor plan with entrance/exit marked, that includes name and address of business. ................
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