| Forms-General |
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11/18/2009 |
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Hospital Burn Unit Packet - The instructions and forms in this packet are designed to
assist providers in submitting the required information to
add a burn unit. |
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11/18/2009 |
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Hospital Rural Health Clinic Packet - The instructions and forms in this packet are designed to
assist providers in submitting the required information to
license a rural health clinic as an outpatient department
of the hospital. The provider will then need to submit
documentation to the Rural Health Clinic Program Manager
for certification in the Medicare/Medicaid program as a
rural health clinic. |
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11/18/2009 |
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Hospital Supplemental PPS-Excluded Psych Unit Packet - The instructions and forms in this packet are designed to
assist providers in submitting the required information
for adding a PPS-excluded psychiatric unit. The Hospital
Bed Change Packet must be submitted with this packet. |
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11/17/2009 |
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Hospital Trauma Center Packet - The instructions and forms in this packet are designed to
assist providers in submitting the required information to
add a trauma center. |
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11/16/2009 |
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Hospital Closure (of the Main Campus and/or Offsite Campus) Packet - The instructions and forms in this packet are designed to
assist providers in submitting the required information in
order to terminate the license of the main campus and/or
offsite campuses. |
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11/16/2009 |
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Hospital Initial Swing Bed Certification Packet - The instructions and forms in this packet are designed to
assist providers in submitting the information needed for
certification of swing beds. |
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11/16/2009 |
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Hospital License Renewal Packet - The information and forms in this packet are designed to
assist hospitals in completing the license renewal process. |
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11/05/2009 |
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ADHC Directory |
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10/27/2009 |
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Tanning Injury Report Form - form used by tanning facilities to document and report
client injuries (or alleged injuries) as a result of using
tanning equipment |
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10/16/2009 |
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Hospital - Initial Licensing & Certification Packet - The information and forms contained in this packet are
designed to assist providers in submitting a complete and
accurate packet for the initial licensing of a hospital.
This packet also contains information and forms needed to
apply for initial certification of the hospital. |
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10/07/2009 |
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CLIA Change of Ownership Packet - These forms must be completed with the CLIA program
independent of any notification to other programs to
complete a change of ownership. |
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10/01/2009 |
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SHARe Forms |
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09/10/2009 |
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Hotel Lodging Exemption Form - From LA Dept of Revenue |
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09/03/2009 |
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Hospital Change of Service Packet - The forms and instructions in this packet are designed to
assist providers in notifying Health Standards of changes
in services provided. This packet should not be used if
the changes in services affect bed/room numbers,
addition/termination of offsite campuses, name/ownership
changes, and relocations. This packet should not be used
for changes that affect swing beds, SNFs, NICUs, PICUs, or
PPS-exempt units. |
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08/25/2009 |
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Background Check Cover Letter Form |
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08/20/2009 |
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Nurse Aide Training Packet - revised 8-14-09 - This Nurse Aide Training Packet, revised 8-14-09, includes
information relative to the use of an approved curriculum.
Providers may choose this option if they prefer to use one
of the approved curriculums when applying for approval of
a Nurse Aide Training School/Program, although there is no
mandate to use this option at this time. |
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08/14/2009 |
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Hospital Entity Name Change Packet (With or Without a DBA Name Change) - This instructions and forms in this packet are to assist
providers in changing the entity name of their hospital,
with or without a corresponding change in the DBA (doing
business as) name of the hospital. If only the DBA name
is changing, please use the Hospital DBA Name Change
Packet instead of this one. If the entity name change is
a result of a change of ownership (CHOW), please use the
Hospital CHOW Packet instead of this one. |
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08/13/2009 |
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Park and Fly Replacement - Replaces email on July 6, 2009 |
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07/27/2009 |
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Hospital CHOW Packet - This packet is designed to assist the provider in
submitting the required information, forms and fees for a
hospital undergoing a Change of Ownership (CHOW). Please
be sure to mail the entire packet to:
Department of Health & Hospitals
Health Standards Section
500 Laurel Street, Suite 100
Baton Rouge, LA 70801
Please submit a copy of the public health application and
plan review application with this packet and send the
originals to corresponding offices. |
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07/21/2009 |
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CLIA Application - CLIA Application to Perform Laboratory Testing |
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07/21/2009 |
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CLIA Survey Informational Packet - Health Standards sends this information to laboratories in
preparation for impending survey. |
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07/13/2009 |
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CSHS Nutrition Manual |
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07/08/2009 |
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2009-2010 LMHPC Membership List (Revised 7-08-09) |
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07/06/2009 |
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2010 Travel Authorization |
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07/01/2009 |
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Hospital (Main Campus &/or Off-Site Campus) Relocation Packet - This packet is designed to assist providers in completing
information to relocate the main campus and/or off-site
campuses of hospitals. Please mail this packet to the
Department of Health & Hospitals, Health Standards
Section, 500 Laurel Street, Suite 100, Baton Rouge, LA
70801. Please submit copies of the public health
application and the plan review application with this
packet and send the originals to the corresponding agency. |
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06/25/2009 |
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Neighborhood Place Intake Form |
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06/25/2009 |
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Neighborhood Place Releases of Information Consent Form |
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06/19/2009 |
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Hospital DBA Name Change Packet - This packet is to be used in submitting changes to the
hospital "DBA" "Doing Business As" name. If a change in
the entity name occurs, please use the "Hospital CHOW
Packet". Please send this packet to the Department of
Health and Hospitals, Health Standards Section, 500 Laurel
Street, Suite 100, Baton Rouge, LA 70801. |
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05/20/2009 |
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Fiscal Year End Close Instructions |
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04/29/2009 |
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Swine Flu Memo - How to Code Expenditures Memo |
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04/28/2009 |
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PPM 7 |
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04/03/2009 |
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SHARe 2-09 SC Training Follow-up Documents |
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03/30/2009 |
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Access - Convert Office 2003 to Office 2007 player - How do I do a task in Office 2007 that I used to do in
Office 2003? |
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03/30/2009 |
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Excel - Convert Office 2003 to Office 2007 player - How do I do a task in Office 2007 that I used to do in
Office 2003? |
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03/30/2009 |
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MS Word - Convert Office 2003 to Office 2007 player - How do I do a task in Office 2007 that I used to do in
Office 2003? |
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03/30/2009 |
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PowerPoint - Convert Office 2003 to Office 2007 player - How do I do a task in Office 2007 that I used to do in
Office 2003? |
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03/19/2009 |
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Reinstatement Policy for Corporate Travel Cards - State of Louisiana |
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03/04/2009 |
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Special Meals Memo |
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02/11/2009 |
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Girl's Basketball Registration Form |
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02/09/2009 |
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Special Meals Form |
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01/09/2009 |
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Take Charge Application |
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12/08/2008 |
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Medicaid Application for Long Term Care |
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12/08/2008 |
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Medicaid Application for Long Term Care |
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11/21/2008 |
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Lead Case Reporting Form - Physicians are required to report blood lead levels that
are 15 µg/dL or greater immediately to LACLPPP. |
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11/21/2008 |
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Lead Poisoning Risk Assessment Questionnaire - To be administered by clinic staff and completed by
parents. |
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11/21/2008 |
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Request for Environmental Investigation Form - Physicians are required to submit Environmental Lead
Investigation Form immediately to LACLPPP with blood
lead levels that are 15 µg/dL - 19 µg/dL after 2 venous
tests, equal or higher than 20 µg/dL. |
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11/20/2008 |
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Key Personnel Change Form - Effective April 15, 2008 all providers are to use this
form to notify Health Standards Section of key personnel
changes (MS Word). Form revised 04/15/09.
*Please do not include SSN or the person's professional
license number (ex: RN license registration number).
Completed forms are public documents.
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11/13/2008 |
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AED Notification Form - This form is to be completed by all entities in possession
of an Automated External Defibrillator (AED) and submitted
to the Bureau of EMS and your local EMS/Fire Dept. in
order to comply with RS40:1236.13. |
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10/27/2008 |
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AOT Checklist (Evaluation / Treatment Plan) |
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10/27/2008 |
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AOT Petition |
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10/07/2008 |
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Nurse Aide Training Change in Coordinator or Clinical Contract - Updated 5-1-09 |
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09/22/2008 |
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Request for Hearing Screening Awareness Brochures |
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09/22/2008 |
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Request for Hearing Screening Refer Brochures |
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09/09/2008 |
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Medication Attendant Certified (MAC) Forms - Facility Application & MAC Medication Error Report Form |
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07/23/2008 |
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Blank Travel Authorization Form |
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07/23/2008 |
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Blank Travel Expense Form |
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07/03/2008 |
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How to Order Nursing Home Blue Books - Nursing Home Blue Book Order Form |
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07/01/2008 |
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2009 Travel Authorization Form - Use after June 30, 2008 |
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07/01/2008 |
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2009 Travel Expense Form - Use after June 30, 2008 |
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06/30/2008 |
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Support Coordination Agency |
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06/25/2008 |
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2009 Travel Guide - Use after June 30, 2008. |
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06/23/2008 |
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Office of Mental Health Facilities Listing |
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06/17/2008 |
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Hospital Off-site Application Packet - Instructions and forms to apply for hospital off-site
campuses. |
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06/10/2008 |
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Hospital Bed Change Packet - Instructions and forms to apply for hospital bed changes. |
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05/14/2008 |
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HSS Complaint Form |
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02/08/2008 |
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Long Term Care Checklist |
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12/05/2007 |
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Long Term Care Application for SSI Recipients |
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11/30/2007 |
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Medicaid Renewal Form |
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11/30/2007 |
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Take Charge Renewal |
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10/11/2007 |
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Take Charge Renewal (SPANISH) |
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09/17/2007 |
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Service Fees |
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09/07/2007 |
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Putative Father Affidavit |
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08/01/2007 |
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Information Request/Order Form - Licensing & certification packets, directories (hard copy
or electronic) may be purchases from Health Standards
Section.(rev 9/22/2009) |
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07/30/2007 |
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Take Charge Renewal |
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07/03/2007 |
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Registration Payment Request Form |
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07/03/2007 |
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Travel Advance Request Form |
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06/04/2007 |
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148 Form - Nursing Facility Care |
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06/04/2007 |
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148W HCBS Waiver Form |
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05/17/2007 |
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Home Health Agency Branch Request Form |
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03/27/2007 |
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Supports Waiver Form |
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03/01/2007 |
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Audiologist's Follow-Up Services Report |
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02/12/2007 |
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Louisiana Confidential Report of Sexually Transmitted Disease - Louisiana Confidential Report of Sexually Transmitted
Disease Form (STD 43) |
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02/12/2007 |
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Louisiana Confidential Report of Sexually Transmitted Disease Instructions - Instructions for completing Louisiana Confidential Report
of Sexually Transmitted Disease Form (STD 43) |
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12/28/2006 |
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Abuse/Neglect Report Form & Instructions (AB03) - HSS-AB-03 is the form used by ICF/DD facilities to report
alleged incidents of abuse or neglect. |
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12/14/2006 |
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Cell Phone Reimbursement |
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12/14/2006 |
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Single Day Meal Allowance |
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12/12/2006 |
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HSS MR 05 Form - ICF/DD Survey Form |
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10/26/2006 |
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DWRLF Addenda and Change Order Guidance (ACOG 8/3/06) - The DWRLF Addenda and Change Order Guidance provides you
with information and requirements regarding submitting
revisions of Project Plans and Specifications and
revisions of Construction Contracts to the DWRLF Program
for approval. |
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10/26/2006 |
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DWRLF Bid Document Guidance (BDG 10/11/04) - The DWRLF Bid Document Guidance provides you with
information and requirements regarding the bidding of
DWRLF projects and submitting the bidding information to
the DWRLF Program. |
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10/26/2006 |
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DWRLF Construction Inspection Guidance (CIG 10/12/04) - The DWRLF Construction Inspection Guidance Document
provides you with information and requirements regarding
the construction inspections of DWRLF projects during
construction. |
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10/26/2006 |
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DWRLF Disadvantaged Business Enterprise Program Forms (8/1/06) - The Disadvantaged Business Enterprise program forms must
be completed for each DWRLF project. See the DWRLF
Disadvantaged Business Enterprise program guidance
document for instructions on how to fill out these forms. |
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10/26/2006 |
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DWRLF Disadvantaged Business Enterprise Program Guidance (DBEG 8/3/06) - The Disadvantaged Business Enterprise program guidance
provides you with information regarding the DWRLF Program
and its requirements for disadvantaged business
participation in projects. |
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10/26/2006 |
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DWRLF Form 1044 Certification of Initiation of Operation (CIO1044 10/26/06) - The DWRLF Form 1044 Certification of Initiation of
Operation must be completed upon finishing the DWRLF
project. |
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09/11/2006 |
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DWRLF Environmental Commenting Agencies List (EIGA 3/7/05) |
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09/11/2006 |
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DWRLF Inter-System Agreements Guidance (ISAG 9/30/04) |
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06/30/2006 |
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Medicaid Form: Declaration of Identity - This document can be used for children under 16 to comply
with requirement to verify identity for all Medicaid
applicants and existing enrollees. |
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05/16/2006 |
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Nurse Aide Training Packet - revised 5-8-09 - The Nurse Aide Training Packet currently in use, revised
5-8-09, requires providers to develop their own
curriculum. Providers may continue to use this process,
until further notice, when applying for approval of a
Nurse Aide Training School/Program. |
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04/11/2006 |
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Louisiana STD Data Request Form |
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02/15/2006 |
- |
Bioterrorism Specimen Submission Manual |
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02/08/2006 |
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Healthcare Provider Survey |
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01/05/2006 |
- |
Disclosure of Ownership Form |
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10/10/2005 |
- |
Hotel Lodging Tax Exemption Form |
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06/17/2005 |
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Replacement Check Request |
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04/14/2005 |
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Employee Address Change Form |
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02/11/2005 |
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Manual Check Request - Manual Check Request |
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02/11/2005 |
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Void Check Request - Void Check Request |
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01/06/2005 |
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FOC Listing Provider Request Form |
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04/28/2004 |
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DHH HIPAA Policies & Forms - The following is a compiled list of HIPAA Policies and
Forms that are to be used by DHH employees. |
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03/22/2004 |
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Emergency Medical Service Fleet Addition |
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03/22/2004 |
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Non Emergency Medical Transportation Fleet Addition |
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02/14/2004 |
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2003 Laboratory Submission Form For Arboviral Testing In Humans |
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