The provider must submit a Letter of Intent to HSS via US mail. Required documents may be submitted with the Letter of Intent.
Below is a list of documents that are required for Initial License Application of a Pain Management Clinic. Submit documents to Health Standards Section.
1. Completed Pain Management Clinic Application Form
2. Completed fire marshal's approval from the Office of the State Fire Marshal
3. Completed health approval from the Louisiana Office of Public Health
4. Appropriate licensing fee: There has been a change in the Payment Procedure please follow the link for instructions.
5. Zoning approval from local government - 8" x 10" floor sketch of your facility showing the required rooms and their sizes.
6. Copy of the clinic's occupational license.
7. Copy of criminal background check from the Louisiana State Police or their authorized agent on all owners.
8. Verification of the physician owners' certification in the sub specialty of pain management in accordance with Section 7803-of the Pain Management Clinic licensure rules
NOTE: LA R.S. 40:2198.12 D. (2) A Pain management clinic that is not licensed by or has not made an application to the department for licensure under this Part on or before August 1, 2014, shall not be licensed under the exemption to Subsection A of this Section as provided for in this Subsection.