Hospital RHC Off-site Addition 

The forms and instructions in this packet are designed to assist providers in submitting the packet to license an offsite campus Rural Health Clinic.  This packet is not to be used to license an independent Rural Health Clinic (please refer to the description below to ensure that you are pursuing the correct avenue to licensure).  Please mail this packet to the Department of Health & Hospitals, Health Standards Section, P.O. Box 3767, Baton Rouge, LA 70821.  Any fees associated with the application should be sent to LDH-Licensing, P.O. Box 62949, New Orleans, LA 70162-2949.

Rural Health Clinic Licensure Decision Tree: There are 3 ways that a Rural Health Clinic can be licensed and certified in Louisiana. Please select the option that you are requesting from the following choices:

1. An independently licensed RHC that is independently certified as a RHC   (If this is the option you want STOP HERE, exit out of the hospital web page and visit the Rural Health Clinic Web Page)

a. This type will not be associated with a hospital.

b. This type will have its own independent license which is not linked with any other facility type.

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

d. This type will submit a CMS 855A to become a certified Rural Health Clinic and check off that it is enrolling as a "Rural Health Clinic"


 2. An independently licensed RHC that is certified as an independent RHC but provider based to the hospital (If this is the option you want STOP HERE, exit out of the hospital web page and visit the Rural Health Clinic Web Page)

a. This type will be associated with a hospital.

b. This type will have its own independent license which is not linked with any other facility type.

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

d. This type will submit a CMS 855A to become a certified Rural Health Clinic, check off that it is enrolling as a "Rural Health Clinic" (not a hospital), and indicate that it will be provider based to the hospital.

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


 3. A RHC that is licensed as an outpatient department of the hospital, certified as an independent RHC but provider based to the hospital.  (If this is the option that you choose then this is the correct packet to send).

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

b. This type will have a HOSPITAL license with "RHC" included in the license number. Please remember that this type must demonstrate that it is 100% owned by the hospital and can't operate separately from the hospital. Example: If the hospital closed, the RHC will automatically close.

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

d. This type will submit a CMS 855A to become a certified Rural Health Clinic, check off that it is enrolling as a "Rural Health Clinic" (not a hospital), and indicate that it will be provider based to the hospital. (Do Not submit a CMS 855A to become a practice location of the hospital)

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

 Accreditation Organizations Approved for Rural Health Clinics

  • AAAASF
  • TSF

 Licensing Forms:

CMS Forms

 Other Agencies:

  • Office of State Fire Marshal Inspections
    • Louisiana Administrative Code 55:V:103 - As of July 1, 2004, the plans and specifications for every structure built or remodeled in the state of Louisiana must be drawn in accordance with the requirements of the specified edition of the Life and Safety Code (excluding Chapter 5 and all TIA's) of the National Fire Protection Association.
    • Most licensing actions require a walk through inspection by the Office of State Fire Marshal. You can contact the Health Care Division of the Office of State Fire Marshal at 800-256-5452 or 225-925-4270. You can also obtain information and instructions online.
  • Office of Public Health Inspections
    • Most licensing actions require a walk through inspection by the Office of Public Health. You can contact Albert Mancuso with the Building & Premises Program of the Office of Public Health at 225-342-7523 to obtain information on scheduling your onsite public health inspection. You can also reach him by email at Albert.Mancuso@la.gov .
    • Please remember that the inspection approval report must indicate the correct name & location of the hospital and/or off-site campus. In addition, the report must indicate the areas being inspected.
  • Louisiana Board of Pharmacy
    • To arrange for your Controlled Dangerous Substance license, call 225-925-6496.
  • Drug Enforcement Agency
  • CLIA