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. |
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|Are you initially licensing this as a RHC? Yes No |
|If no, what is the current license number for this RHC? |
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|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? |
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|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 |
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|Key Personnel |
|Medical Director’s Name |
|Names of Other Physicians |
|Names of Advanced Practice Nurses |
|Names of Physician Assistants |
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|Will the FNP be on site at least 50% of the time that the RHC has patients as required: Yes No |
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|Hours of Operation: |
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|Monday |
|Tuesday |
|Wednesday |
|Thursday |
|Friday |
|Saturday |
|Sunday |
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|Hours |
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|Other details: |
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