Department of Health | State of Louisiana



|Letter of Intent |

|There are 3 ways that a RHC can be licensed & certified. Please identify the route you are requesting: |

|An independently licensed RHC that is independently certified as a RHC |

|This type will not have “RHC” in the license number |

|This type will submit a Rural Health Clinic license application to become a licensed RHC (not a hospital license application) |

|This type will submit a CMS 855A to become a certified Rural Health Clinic |

|STOP if you checked this box and complete the Rural Health Clinic Application Process rather than the Hospital Offsite Campus Application Process. |

|An independently licensed RHC that is certified separately from the hospital but provider based to the hospital |

|This type will not have “RHC” in the license number |

|This type will submit a Rural Health Clinic license application to become a licensed RHC (not a hospital license application) |

|This type will submit a CMS 855A to become a Rural Health Clinic and indicate that it will be provider based to the hospital |

|Please keep in mind that this type must be able to demonstrate compliance with provider based requirements if asked by CMS |

|STOP if you checked this box and complete the Rural Health Clinic Application Process rather than the Hospital Offsite Campus Application Process. |

|A RHC that is licensed as an outpatient department of the hospital and certified separately from the hospital but provider based to the hospital. (This is the |

|correct form for this action) |

|Only hospitals with fewer than 50 beds can be considered for this option |

|This type will have a license with “RHC” included in the license number. |

|This type will submit a Hospital license application to become a licensed outpatient department of the hospital (not a Rural Health Clinic license application) |

|This type will submit a CMS 855A to become a Rural Health Clinic that is provider based to the hospital (Do Not submit a CMS 855A to become a practice location of |

|the hospital) |

|Please keep in mind that this type must be able to demonstrate compliance with provider based requirements if asked by CMS |

|Use this form, in addition to the Hospital Offsite Campus Application, if you are initially licensing a RHC as a hospital offsite campus outpatient RHC department |

|of a hospital or converting from an independently licensed RHC to become a hospital offsite campus outpatient RHC department. |

| |

|Are you initially licensing this as a RHC? Yes No |

|If no, what is the current license number for this RHC?       |

| |

|Are you converting this from a non-RHC outpatient department of a hospital to a RHC outpatient department of a hospital? No Yes |

|If yes, what is the license number of the currently licensed outpatient department of the hospital?       |

| |

|Does the Rural Health Clinic have its own entrance and signage separate from other tenants, if there are other tenants in the building: |

|Yes No |

| |

|Key Personnel |

|Medical Director’s Name |

|Names of Other Physicians |

|Names of Advanced Practice Nurses |

|Names of Physician Assistants |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|Will the FNP be on site at least 50% of the time that the RHC has patients as required: Yes No |

| |

|Hours of Operation: |

| |

|Monday |

|Tuesday |

|Wednesday |

|Thursday |

|Friday |

|Saturday |

|Sunday |

| |

|Hours |

|      |

|      |

|      |

|      |

|      |

|      |

|      |

| |

| |

|Other details: |

|      |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download