"Certificate of Need Application Packet" - Connecticut

Certificate of Need Application Packet is a legal document that was released by the Connecticut State Department of Social Services - a government authority operating within Connecticut.

Form Details:

  • The latest edition currently provided by the Connecticut State Department of Social Services;
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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Social Services.

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Download "Certificate of Need Application Packet" - Connecticut

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Application Checklist
Instructions:
1. Please check each box below, as appropriate; and
2. The completed checklist
must
be submitted as the first page of the
CON application.
Attached is the CON application filing fee in the form of a
certified, cashier or business check made out to the “Treasurer
State of Connecticut” in the amount of $500.
For OHCA Use Only:
Docket No.: ______________
Check No.: ________
OHCA Verified by:__________ Date: ____________
Attached is evidence demonstrating that public notice has been
published in a suitable newspaper that relates to the location of
the proposal, 3 days in a row, at least 20 days prior to the
submission of the CON application to OHCA. (OHCA requests
that the Applicant fax a courtesy copy to OHCA (860) 418-
7053, at the time of the publication)
Attached is a paginated hard copy of the CON application
including a completed affidavit, signed and notarized by the
appropriate individuals.
Attached are completed Financial Attachments I and II.
Submission includes one (1) original and four (4) hard
copies with each set placed in 3-ring binders.
Note: A CON application may be filed with OHCA electronically
through email, if the total number of pages submitted is 50
pages or less. In this case, the CON Application must be
emailed to the following email addresses:
steven.lazarus@ct.gov
and leslie.greer@ct.gov.
Important: For CON applications(less than 50 pages) filed
electronically through email, the signed affidavit and the check
in the amount of $500 must be delivered to OHCA in hardcopy.
The following have been submitted on a CD
1. A scanned copy of each submission in its entirety, including
all attachments in Adobe (.pdf) format.
2. An electronic copy of the documents in MS Word and MS
Excel as appropriate.
i
Application Checklist
Instructions:
1. Please check each box below, as appropriate; and
2. The completed checklist
must
be submitted as the first page of the
CON application.
Attached is the CON application filing fee in the form of a
certified, cashier or business check made out to the “Treasurer
State of Connecticut” in the amount of $500.
For OHCA Use Only:
Docket No.: ______________
Check No.: ________
OHCA Verified by:__________ Date: ____________
Attached is evidence demonstrating that public notice has been
published in a suitable newspaper that relates to the location of
the proposal, 3 days in a row, at least 20 days prior to the
submission of the CON application to OHCA. (OHCA requests
that the Applicant fax a courtesy copy to OHCA (860) 418-
7053, at the time of the publication)
Attached is a paginated hard copy of the CON application
including a completed affidavit, signed and notarized by the
appropriate individuals.
Attached are completed Financial Attachments I and II.
Submission includes one (1) original and four (4) hard
copies with each set placed in 3-ring binders.
Note: A CON application may be filed with OHCA electronically
through email, if the total number of pages submitted is 50
pages or less. In this case, the CON Application must be
emailed to the following email addresses:
steven.lazarus@ct.gov
and leslie.greer@ct.gov.
Important: For CON applications(less than 50 pages) filed
electronically through email, the signed affidavit and the check
in the amount of $500 must be delivered to OHCA in hardcopy.
The following have been submitted on a CD
1. A scanned copy of each submission in its entirety, including
all attachments in Adobe (.pdf) format.
2. An electronic copy of the documents in MS Word and MS
Excel as appropriate.
i
AFFIDAVIT
Applicant: ____________________________________________________
Project Title: __________________________________________________
__________________________________________________
I, _____________________________, _________________________________
(Position Title – CEO or CFO)
(Individual’s Name)
of _____________________________ being duly sworn, depose and state that
(Hospital or Facility Name)
_____________________________’s information submitted in this Certificate of
(Hospital or Facility Name)
Need Application is accurate and correct to the best of my knowledge.
______________________________________
__________________
Signature
Date
Subscribed and sworn to before me on________________________
_______________________________________________________
Notary Public/Commissioner of Superior Court
My commission expires: ___________________________________
ii
State of Connecticut
Office of Health Care Access
Certificate of Need Application
Instructions: Please complete all sections of the Certificate of Need (“CON”)
application. If any section or question is not relevant to your project, a response of “Not
Applicable” may be deemed an acceptable answer. If there is more than one applicant,
identify the name and all contact information for each applicant. OHCA will assign a
Docket Number to the CON application once the application is received by OHCA.
Docket Number:
Applicant:
Applicant’s Facility ID*:
Contact Person:
Contact Person’s
Title:
Contact Person’s
Address:
Contact Person’s
Phone Number:
Contact Person’s
Fax Number:
Contact Person’s
Email Address:
Project Town:
Project Name:
Statute Reference:
Section 19a-638, C.G.S.
Estimated Total
Capital Expenditure:
*Please provide either the Medicare, Connecticut Department of Social Services (DSS), or National Provider
Identifier (NPI) facility identifier.
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1. Project Description: Service Termination
a. For each of the Applicant’s programs, identify the location, population served,
hours of operation, and whether the program is proposed for termination.
b. Describe the history of the services proposed for termination, including when they
were begun and whether CON authorization was received.
c. Explain in detail the Applicant’s rationale for this termination of services, and the
process undertaken by the Applicant in making the decision to terminate.
d. Did the proposed termination require the vote of the Board of Directors of the
Applicant? If so, provide copy of the minutes (excerpted for other unrelated
material) for the meeting(s) the proposed termination was discussed and voted on.
e. Explain why there is a clear public need for the proposal. Provide evidence that
demonstrates this need.
2. Termination’s Impact on Patients and Provider Community
a. Identify the name and location (i.e. address, town and state), facility ID and hours
of operation (as available) of existing providers in the towns listed above and in
nearby towns;
TABLE 1
EXISTING SERVICE PROVIDERS
Days/Hours of
Facility Name
Facility ID*
Facility Address
Service
Operation
*Please provide either the Medicare, Connecticut Department of Social Services (DSS), or National Provider
Identifier (NPI) facility identifier and label column with the identifier used.
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b. For each provider to whom the Applicant proposes to transfer or refer clients,
provide the facility ID, total capacity, current available capacity, as well as the
utilization for the last completed year and for the current year.
TABLE 2
PROVIDERS ACCEPTING TRANSFERS/REFERRALS
Utilization
Total
Available
Utilization
Facility Name
Facility ID*
Facility Address
Current
Capacity
Capacity
FY XX**
CFY***
*Please provide either the Medicare, Connecticut Department of Social Services (DSS), or National Provider
Identifier (NPI) facility identifier and label column with the identifier used.
**Fill in year and identify the period covered by the Applicant’s FY (e.g. July 1-June 30, calendar year, etc.). Label and provide the
number of visits or discharges as appropriate.
***For periods greater than 6 months, report annualized volume, identifying the number of actual months covered and the method of
annualizing. For periods less than six months, report actual volume and identify the period covered.
c. Identify any special populations that utilize the service(s) and explain how these
populations will maintain access to the service following termination at the
specific location; also, specifically address how the termination of this service
will affect access to care for Medicaid recipients and indigent persons.
d. What impact will the proposal have upon the cost effectiveness of providing
access to services provided under the Medicaid program? If not applicable to the
proposal, explain why it is not applicable.
e. Provide evidence (e.g. written agreements or memorandum of understanding) that
other providers in the area are willing and able to absorb the displaced patients.
f. Describe how clients will be notified about the termination and transfer to other
providers.
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