DEPARTMENT OF HEALTH HEALTH STANDARDS SECTION

HOME AND COMMUNITY BASED SERVICES LICENSE APPLICATION

INITIAL RENEWAL CHANGE OF OWNERSHIP CHANGE OF ADDRESS ADD BRANCH OR SATELLITE
ADD a SERVICE DELETE a SERVICE LICENSE NUMBER ______EXPIRATION DATE ______
TOTAL FEE AMOUNT sent to PO Box 62949, New Orleans, LA 70162 ______CHECK / MONEY ORDER # ______
*If adding or deleting a service, you must indicate which HCBS service module is being added or deleted by checking the appropriate box in the Service Module section below.
SERVICE MODULES
If applying for license renewal, please check all services currently being provided. Additional service modules may not be added with license renewal.
PCA SIL SIL Shared Living Conversion Family Support Respite In-Home
Respite Center Based MIHC Supported Employment Substitute Family Care ADC

CHECK IF ANY CHANGE HAS OCCURRED SINCE LAST APPLICATION STATE ID #HC ______
I.
AGENCY (DBA) NAME ______
GEOGRAPHICAL ADDRESS ______
CITY / STATE / ZIP ______
TELEPHONE NUMBER (_____) ______FAX NUMBER (____) ______EMAIL ADDRESS______
REGION ______PARISH ______
II.
MAILING ADDRESS (IF DIFFERENT FROM ABOVE) ______
CITY / STATE / ZIP ______
III.
POPULATION SERVED: MALE FEMALE BOTH ADMISSION AGE RANGE: ______YRS. TO ______YRS.
IV. DAYS OPEN DURING WEEK ( Circle) MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
HOURS OF OPERATION ____ a.m. _____ p.m. TO _____ a.m. _____ p.m.
LICENSED CAPACITY Center Based Respite ______ADC ______
NUMBER OF BUILDINGS USED BY CLIENTS (CENTER BASED SERVICES ONLY) _____
NON- PROFIT
INDIVIDUAL/SOLE PROPRIETOR
CORPORATION
PARTNERSHIP
RELIGIOUS AFFILIATION
UNINCORPORATED ASSOCIATION
OTHER (Specify): ______ / FOR – PROFIT
INDIVIDUAL/SOLE PROPRIETOR
CORPORATION
PARTNERSHIP
GROUP PRACTICE
OTHER (Specify): ______
/ GOVERNMENT
FEDERAL
STATE
PARISH
CITY/PARISH
CITY
COMBINATION GOV-N-PROFIT
OTHER (Specify) ______
VI.
ENTITY / CORPORATION NAME ______
MAILING ADDRESS (IF DIFFERENT) ______
CITY / STATE / ZIP ______
TELEPHONE NUMBER (______) ______FAX NUMBER (_____) ______
VII. List name, address, and telephone numbers for persons or group of persons having direct or indirect ownership or a controlling interest 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 / ADDRESS / TELEPHONE #
VIII. If the disclosing entity is a corporation, list name, address and telephone number of the President.
NAME / ADDRESS / TELEPHONE NUMBER
IX. Are any owners of the disclosing entity also owners of other licensed health care facilities? Yes No
(Proprietorship, Partnership or Board Member) If yes, list names, addresses of individuals and other provider numbers.
NAME / ADDRESS / PROVIDER NUMBER
X. Has there been a change of ownership or control within the last year? Yes No If yes, give date:______
XI. ADMINISTRATOR
NAME: ______
HOME ADDRESS: ______
HOME TELEPHONE NUMBER: (____)______DATE HIRED AS : ______
EDUCATIONAL BACKGROUND: Degree Earned - ______Date Earned - ______
Institution - ______
CHECK IF ANY CHANGE HAS OCCURRED SINCE LAST APPLICATION. ATTACH RESUME IF ADMINISTRATOR HAS CHANGED.
XII. SATELLITE/ BRANCH OFFICES (Requires approval from Health Standards prior to opening and may not be requested at renewal)
BRANCH/SATELLITE NAME / STREET ADDRESS / CITY/PARISH/ZIP / PHONE
NUMBER / FAX
NUMBER
CHECK IF ANY CHANGE HAS OCCURRED SINCE LAST APPLICATION
XIII. ACCREDITATION Accrediting Organization : JCAHO CARF COA Current Term of Accreditation: From ______Through ______
ATTESTATION:
I understand that if the agency license is granted, it is granted for one year and shall become void upon change of ownership. It is my responsibility to notify the Department of Health, Health Standards Section in writing of any changes in the information provided in this application. 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 Department of Health.
______
AUTHORIZED REPRESENTATIVE NAME (TYPED OR PRINTED)
______
AUTHORIZED REPRESENTATIVE SIGNATURE DATE

HSS-HCBS-01 (issued 5/11, revised 08/11, 12/11, 01/14, 07/17)