Rural Health Clinic Site Verification Submission

Please complete this form to request a letter to be submitted from Well-Ahead Louisiana’s State Office of Rural Health to Louisiana Health Standards Section verifying that an address meets the geographic requirements for a rural health clinic.

Your Name(Required)

Your Email Address(Required)

Role with Clinic(Required)

Are you the primary contact?(Required)

Yes

Primary Contact(Required)

Primary Contact Email Address(Required)

Entity’s Legal Name(Required)

Legal name of entity that owns/will own RHC at this location. This name must match exactly what is listed on the TIN/EIN form, including punctuation.

Entity’s Address for Verification(Required)

Include ZIP code and suite number if applicable.

Additional Address for Verification

If the entity’s address does not qualify for RHC development, please list any other addresses you would like to verify.

Is there currently a clinic (RHC or FFS) at this address?(Required)

Yes

Current Clinic’s Name(Required)

This field is for validation purposes and should be left unchanged.