Louisiana Department of Health & Hospitals | Kathy Kliebert, Secretary

Statewide Initiatives

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Hospital Initial Licensure and 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.

CMS forms must be obtained from CMS website. Please refer to the checklist for a list of CMS required forms

  • Cover Sheet for Initials
  • Initial Licensing - Medicare & Medicaid Certification
  • Memo Regarding Initial Medicare Surveys
  • S&C 08-03
  • Q & A About Completing the Section for Bed Changes in Hospitals
  • License Application
  • Checklist for Hospital Licensure & Certification
  • Disclosure of Ownership
  • Worksheet for Hospital Beds & Rooms (licensed or nonlicensed)
  • Attestation Letter
  • Plan Review
  • Plan Review Attestation
  • Public Health
  • CLIA
  • Fiscal Year-End Date
  • Notification of Co-Located Status
  • Health Standards Fees
  • Office of Civil Rights