Initial License / Change of Information (CHOI)
Change of Ownership (CHOW)
Section 2: Hospital Information (Must Be Completed)
Applying for Initial Licensing / Main Campus License # / State ID:H0000
Facility(Main Campus DBA) Name and Geographical Address:
Parish of Hospital: / Fiscal Intermediary: / Fiscal Year End:
Accrediting Body: / Accreditation Exp:
Is the hospital co-located on the campus or in the building of another hospital? No Yes
If yes, list the name of the hospital:
Section 3: Type of Facility (Must Be Completed)
Acute Care Hospital / Long Term Acute Care Hospital / Critical Access Hospital
Psychiatric Hospital / Rehabilitation Hospital / Children’s Hospital
Section 4: Administration (Must Be Completed)
Administrator / Director of Nursing
Name: / Name:
Phone: / Phone:
Email: / Email:
Designated Contact Person
Name: / Email:
Phone:
Section 5: Type of Ownership (Must Be Completed)
Non-Profit (Must submit evidence of Non-profit status) / For Profit / Government (Must submit evidence of Governmental status)
Individual/Sole Proprietor / Individual/Sole Proprietor / Federal Facility
Corporation / Corporation / Hospital Service District
Limited Liability Corporation / Limited Liability Company / State Facility
Partnership / Partnership / Combination Gov-N-Profit
Religious Affiliation / Group Practice / Parish (specify)
Unincorporated Association / Other: / Other
Other:
Section 6: Legal Entity/Corporation (Must Be Completed) Submit IRS documentation showing legal name & EIN
Legal Entity/Corporation Name:
Legal Entity/Corporation Mailing Address:
Legal Entity/Corporation City/State/Zip:
Legal Entity/Corporation Phone #: / Legal Entity/Corporation Fax #:
Section 7: Payment Information (Must Be Completed if there is a Fee Associated with This Action)
Check or Money Order Number:
Mail Payment & Payment Transmittal Form To / Email License Application To
DHH Licensing Fee
PO Box 62949
New Orleans, LA 70162-2949 /
Name of Hospital:
Section 8: Ownership (Must Be Completed)List name, address, and telephone numbers for persons or groups of persons, or the employer identification number (EIN) for organizations having direct or indirect ownership or a controlling interest (5% or more) of the corporate stock or partnership interest or any person or business entity which has a direct business interest, including, but not limited to, a wholly owned subsidiary, the details of any conversion rights which may exist for the benefit of any party and whether such stock, partnership interest, or ownership being held by the disclosed person or business entity is, in fact, owned by another person or business entity. (Attach additional sheets if additional space is needed).
Owner Name / Address
Section 9: Corporation Ownership ( Not applicable)
If the disclosing entity is a corporation, list name, address, and telephone number of the President
President’s Name / President’s Address / President’s Telephone #
Section 10: Intention Regarding Certification (Must Be Completed for Initial Licensing)
Once licensed, will you be pursuing Medicare Certification:
No
Yes
Please see the website for additional documents needed for certification.
Once licensed (please note that you CANNOT be accredited prior to licensing), which Accrediting Organization will you be pursuing certification through:
Section 11: Intention Regarding Certification (Must Be Completed for a CHOW)
A provider who is contemplating or negotiating a CHOW must notify CMS (42 CFR §489.18(b)). Indicate if the prospective owners will participate in the Medicare program by checking the appropriate sections below:
Prospective owner has read Section 3210.5 of the State Operations Manual and 42 CFR 489.12 (Code of Federal Regulations) and understands the options.
If you decide not to accept the terms of the Medicare Provider Agreement, you have the option to:
· Apply for a new Medicare number, or
· Choose not to participate in the Medicare program
Prospective owner does not intend to participate in the Medicare program.
Prospective owner intends to participate in the Medicare program.
Prospective owner accepts assignment of the previous owner’s provider agreement.
Prospective owner to apply for a new provider agreement.
Section 12: Rooms/Beds Totals for Entire Hospital (Must Be Completed)
Total # of licensed rooms for hospital (include all rooms in the main campus and off-site campuses that are counted on the HSS-HO-16a Worksheet for Hospital Beds & Rooms):
Total # of non-licensed beds for hospital (include all beds in the main campus and off-site campuses that are counted on the HSS-HO-16b Worksheet for Hospital Beds & Rooms):
Swing Beds (List how many of the above beds are swing beds)
Section 13a: Rooms/Beds Counted As Licensed Rooms/Beds (Must Be Completed)
Included HSS-HO-016a Worksheet for Hospital Beds & Rooms
Name of Hospital:
Section 13b: Rooms/Beds Not Counted As Licensed Rooms/Beds ( Not applicable)Included HSS-HO-016b Worksheet for Hospital Beds & Rooms
Section 14: Off-Site Campuses ( Not applicable)
To include all sites being billed under the hospital’s provider agreement or any NPI numbers associated with the hospital
(Please copy this page and use for additional off-site campus information if needed)
License # / Off-Site DBA Name & Address / Services / Parish / Phone
(Direct line-no voice mail) / Fax
Offsite Name as it will appear on the license:
Offsite Address:
Offsite Name as it will appear on the license:
Offsite Address:
Offsite Name as it will appear on the license:
Offsite Address:
Offsite Name as it will appear on the license:
Offsite Address:
Section 15: CHOW/CHOI Effective Date (Must Be Completed for a CHOW/CHOI)
What is the effective date for this transaction?:
Section 16: Attestation & Signature
I understand that if the agency license is granted, it is granted for one year and shall become void upon change of ownership or change in geographical address. It is my responsibility to notify the Louisiana Department of Health, Health Standards Section, in writing of any changes in the information provided in this application in a separate packet. I attest that the Hospital currently complies with the requirements of the Office of State Fire Marshal, Office of Public Health and building codes. I certify that the information herein is true, correct and supportable by documentation to the best of my knowledge. Documentation of the information above is available upon request by the Louisiana Department of Health.
Authorized Representative’s Printed Name & Title:
Authorized Representative’s Signature: / Date:
Name of Hospital:
Section 17: Required Licensing Information to Attach to this ApplicationPlease attach all items denoted by “X” below for the type of application you are submitting. Please don’t attach extraneous information or information not requested for your licensing action.
Item / Initial Licensing / CHOW / CHOI
1) HSS-HO-57 Initial/CHOW/CHOI Application / X / X / X
2) DH Plan Review Released to HSS / X
3) DH Plan Review Attestation / X
4) OSFM Life Safety Plan Review Released to HSS or Exemption Received (AR review) / X
5) OSFM Walk Through Inspection showing the dba name of the hospital and geographical address. Include offsite(s) if applicable. / X / X / X
6) OPH Walk Through Inspection showing the dba name of the hospital and geographical address. Include offsite(s) if applicable. / X / X / X
7) OPH Retail Food Permit showing the dba name of the hospital and geographical address. Include offsite(s) if applicable. / X / X / X
8) HSS-HO-016a Worksheet for Hospital Beds & Rooms / X / X
9) HSS-HO-016b Worksheet for Hospital Beds & Rooms / X / X
10) Copy of Payment Transmittal and Copy of the Check / X / X
11) Please refer to our website for federal documents that are required in order to process this application. / X / X / X
12) Before and after diagram of the Ownership Structure showing all person/entities with a 5% or greater direct or indirect ownership/control/interest/membership in any of the entities in the hospital’s ownership structure. / X / X / X
13) IRS Documentation showing the Legal Business Name and Tax ID number / X / X / X
14) Legal transaction documents / X / X
HSS-HO-057 8/2017