Name of Hospital

Health Standards Section Hospital License Application Main Campus Relocation Main Campus/Offsite Campus Re-designation

Section 1: Licensing Action (Must Be Completed) A. Main Campus Relocation B. Main Campus/Offsite Campus Re-Designation (to be used when relocating the main campus of the hospital) (to be used when an offsite campus will be re-designated as the (Do not use this form for an offsite campus relocation) main campus and the current main campus will be re- designated as an offsite campus) Relocating the Main Campus with No Impact to Offsite Re-designation with No Impact to Offsite Campus

Campuses (other than the swap) Relocating the Main Campus with Impact to Offsite Re-designation with Impact to Offsite Campus

Campuses

HSS-HO-01d 12/2017 Section 2: Hospital Main Campus Relocation (Must Be Completed if You Checked Off Any Items in Section 1 A ) Current Main Campus Information Proposed Main Campus Information License # Geographical Address: Parish: Co-located on the campus No Yes No Yes or in the building of another hospital? If yes, list the name of the hospital: If yes, list the name of the hospital:

Are there other buildings on No Yes No Yes this campus? If yes, please complete section 9(a) in addition to If yes, please complete section 9(b) in addition to other other required sections. required sections. Will any Offsite Campuses Be Impacted by this Relocation: No Yes

If yes, please complete section 8 in addition to other required sections. Accrediting Body: Accreditation Exp:

HSS-HO-01d 12/2017 Section 3: Hospital Main Campus/Offsite Campus Re-designation (Must Be Completed if You Checked Off Any Items in Section 1 B ) Current Main Campus Information Current Offsite Campus Information License # Geographical Address: Parish: Co-located on the campus No Yes No Yes or in the building of another hospital? If yes, list the name of the hospital: If yes, list the name of the hospital:

Are there other buildings on No Yes No Yes this campus? If yes, please complete section 9(a) in addition to If yes, please complete section 9(b) in addition to other other required sections. required sections. Will any Other Offsite Campuses Be Impacted by this Re-Designation: No Yes

If yes, please complete section 8 in addition to other required sections.

Section 4: 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 5: Payment Information (Must Be Completed) Check or Money Order Number: Mail Payment & Payment Transmittal Form To Email License Application To

DHH Licensing Fee PO Box 62949 [email protected] New Orleans, LA 70162-2949 Name of Hospital:

Section 6: Administration (Must Be Completed) Administrator Director of Nursing Contact Person Name: Phone: Email:

Section 7: 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 Main Campus: Offsite Campus campuses that are counted on the HSS-HO-16a Worksheet for Hospital Beds & Rooms) upon completion of this action: Total # of non-licensed beds for hospital (include all beds in the main campus and off- Main Campus: Offsite Campus: site campuses that are counted on the HSS-HO-16b Worksheet for Hospital Beds & Rooms) upon completion of this action: Swing Beds (List how many of the above beds are swing beds)

HSS-HO-01d 12/2017 Section 7a: Rooms/Beds Counted As Licensed Rooms/Beds (Must Be Completed) Included HSS-HO-016a Worksheet for Hospital Beds & Rooms

HSS-HO-01d 12/2017 Section 7b: Rooms/Beds Not Counted As Licensed Rooms/Beds ( Not applicable)

Included HSS-HO-016b Worksheet for Hospital Beds & Rooms

Section 8: 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 & Services Parish Phone Fax # Address (Direct line-no voice mail) 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:

Name of Hospital:

Section 9a: Service Location Information for Locations that are on the Currently Licensed Main Campus but have a Different DBA Name or Different Geographical Address from the Licensed Main Campus of the Hospital (To be completed for any locations held out to the public as part of the hospital, or reported on the hospital’s allowable cost report, or billed under the hospital’s NPI numbers) DBA Name of Location Building Name Single or Single or 911 Geographical Address including General Description of Where Services are Where Services Are Multi Multi Suite Numbers, City, and Zip code Services Provided Located Story Occupancy (Attach Site Map Attach identifying Building) Floor Map showing location of service within the building

HSS-HO-01d 12/2017 Section 9b: Service Location Information for Locations that are on the Currently Licensed Offsite Campus but have a Different DBA Name or Different Geographical Address from a Licensed Offsite Campus of the Hospital (To be completed for any locations held out to the public as part of the hospital, or reported on the hospital’s allowable cost report, or billed under the hospital’s NPI numbers) DBA Name of Location Building Name Single or Single or 911 Geographical Address including General Description of Where Services are Where Services Are Multi Multi Suite Numbers, City, and Zip code Services Provided Located Story Occupancy (Attach Site Map Attach identifying Building) Floor Map showing location of service within the building

Section 10: 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:

HSS-HO-01d 12/2017 Section 11: Required Licensing Information to Attach to this Application Please 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.

Main Campus Relocation Main Campus/Offsite Campus Re-designation

1) HSS-HO-01c Main Campus Relocation or Main Campus/Offsite Campus Re- X designation Application 2) DH Plan Review Released to HSS (inclusive of site map (showing all buildings, X parking & streets), floor map, & floor plans. 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 X geographical address. Include offsite(s) if applicable. 6) OPH Walk-Through Inspection showing the dba name of the hospital and X geographical address. Include offsite(s) if applicable. 7) OPH Retail Food Permit showing the dba name of the hospital and geographical X address. Include offsite(s) if applicable. 8) HSS-HO-016a Worksheet for Hospital Beds & Rooms X 9) HSS-HO-016b Worksheet for Hospital Beds & Rooms X 10) Copy of Payment Transmittal and Copy of the Check X 11) Return of Original Licenses for Locations Prior to this Action X 12) Please refer to our website for federal documents that are required in order to X process this application. 13) Please note that if the locations impacted have Swing Beds, SNF Beds, PPS X Excluded Psychiatric Beds, and/or PPS Excluded Rehab Beds, you will need to include that on the CMS 855A.

HSS-HO-01d 12/2017