"Certificate of Need Equipment Replacement Notification Form" - Connecticut

Certificate of Need Equipment Replacement Notification Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

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Download "Certificate of Need Equipment Replacement Notification Form" - Connecticut

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STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
Office of Health Care Access
Certificate of Need Equipment Replacement Notification Form
Pursuant to 19a-638(b)(18), an existing imaging equipment may be replaced, if such
equipment was acquired through certificate of need approval or a certificate of need
determination, provided a health care facility, provider physician or a person notifies
OHCA of the date on which the equipment is replaced and the disposition of the replaced
equipment.
Please complete the following:
Provider Name & Address:
Name and description of the equipment to be
replaced:
Docket or Report number of the CON
authorization of the existing imaging
equipment being replaced:
Address of the existing imaging equipment:
Name and description of the replacement
equipment:
Location where replacement equipment will be
operated:
The date the replaced equipment was replaced:
The disposition of the replaced equipment
Person Completing the form:_____________________, __________________
Name
Title
____________________, __________________
Signature
Date
An Equal Opportunity Employer
410 Capitol Ave., MS#13HCA, P.O.Box 340308, Hartford, CT 06134-0308
Telephone: (860) 418-7001 Toll-Free: 1-800-797-9688
Fax: (860) 418-7053
STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
Office of Health Care Access
Certificate of Need Equipment Replacement Notification Form
Pursuant to 19a-638(b)(18), an existing imaging equipment may be replaced, if such
equipment was acquired through certificate of need approval or a certificate of need
determination, provided a health care facility, provider physician or a person notifies
OHCA of the date on which the equipment is replaced and the disposition of the replaced
equipment.
Please complete the following:
Provider Name & Address:
Name and description of the equipment to be
replaced:
Docket or Report number of the CON
authorization of the existing imaging
equipment being replaced:
Address of the existing imaging equipment:
Name and description of the replacement
equipment:
Location where replacement equipment will be
operated:
The date the replaced equipment was replaced:
The disposition of the replaced equipment
Person Completing the form:_____________________, __________________
Name
Title
____________________, __________________
Signature
Date
An Equal Opportunity Employer
410 Capitol Ave., MS#13HCA, P.O.Box 340308, Hartford, CT 06134-0308
Telephone: (860) 418-7001 Toll-Free: 1-800-797-9688
Fax: (860) 418-7053