Form CN-8 "Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility" - New Jersey

What Is Form CN-8?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CN-8 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form CN-8 "Project Application for Expansion Slots at a Licensed Adult Day Health Services Facility" - New Jersey

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New Jersey Department of Health
Division of Certificate of Need and Licensing
Office of Certificate of Need and Healthcare Facility Licensure
PROJECT APPLICATION FOR EXPANSION SLOTS AT A LICENSED ADULT DAY HEALTH SERVICES FACILITY
INSTRUCTIONS: Complete all questions directly on this form. Completed application packages, which includes a cover letter and
two (2) copies of the project narrative, the fee, and architectural plans are to be sent to:
Assistant Director
Certificate of Need and Healthcare Facility Licensure
New Jersey Department of Health
Mailing Address:
Overnight Services (DHL, FedEx, UPS):
PO Box 358
25 South Stockton Street, 2nd Floor
Trenton, NJ 08625-0358
Trenton, NJ 08608-1832
A non-refundable application fee (Government agencies are exempt) MUST accompany each application. Please make
check payable to "Treasurer, State of New Jersey."
$10 (per slot) X
(number of slots) = $
+ $1,500 = $
If you have any questions, you may contact the program at (609) 633-9042.
GENERAL INFORMATION
1.
Name of Facility
2.
Street Address of Facility
3.
City, State, Zip
4.
County
5.
Name of Contact Person for Project Application 6.
Email Address
7.
Telephone Number
PROGRAM INFORMATION
8.
Number of licensed adult day health services slots requested:
__________
9.
Current Days and Hours of Operation:
10. Number of Current Sessions:
11. Proposed Days and Hours of Operation:
12. Number of Proposed Sessions:
CN-8 (formerly HFEL-4)
MAY 16
Page 1 of 2 Pages.
New Jersey Department of Health
Division of Certificate of Need and Licensing
Office of Certificate of Need and Healthcare Facility Licensure
PROJECT APPLICATION FOR EXPANSION SLOTS AT A LICENSED ADULT DAY HEALTH SERVICES FACILITY
INSTRUCTIONS: Complete all questions directly on this form. Completed application packages, which includes a cover letter and
two (2) copies of the project narrative, the fee, and architectural plans are to be sent to:
Assistant Director
Certificate of Need and Healthcare Facility Licensure
New Jersey Department of Health
Mailing Address:
Overnight Services (DHL, FedEx, UPS):
PO Box 358
25 South Stockton Street, 2nd Floor
Trenton, NJ 08625-0358
Trenton, NJ 08608-1832
A non-refundable application fee (Government agencies are exempt) MUST accompany each application. Please make
check payable to "Treasurer, State of New Jersey."
$10 (per slot) X
(number of slots) = $
+ $1,500 = $
If you have any questions, you may contact the program at (609) 633-9042.
GENERAL INFORMATION
1.
Name of Facility
2.
Street Address of Facility
3.
City, State, Zip
4.
County
5.
Name of Contact Person for Project Application 6.
Email Address
7.
Telephone Number
PROGRAM INFORMATION
8.
Number of licensed adult day health services slots requested:
__________
9.
Current Days and Hours of Operation:
10. Number of Current Sessions:
11. Proposed Days and Hours of Operation:
12. Number of Proposed Sessions:
CN-8 (formerly HFEL-4)
MAY 16
Page 1 of 2 Pages.
PROJECT APPLICATION FOR EXPANSION SLOTS AT A LICENSED ADULT DAY HEALTH SERVICES FACILITY
(CONTINUED)
Name of Facility
PROGRAM INFORMATION, Continued
13. Provide scaled architectural floor plans with dimensions. Plans shall delineate the existing and proposed conditions, and label
spaces with their intended use.
Will renovations and/or new construction be required to accommodate the additional slots?
No
Yes
If yes, describe to what extent (constructing a new building, adding an addition to an existing structure, alteration or renovation
of an existing facility, and what other structures are on the property and the surrounding properties).
14. Additional Information/Remarks
CERTIFICATION: I certify that the information provided in this application is true and correct to the best of my knowledge
and belief. I understand and agree not to implement any portion of this proposal prior to receiving written approval
from the Certificate of Need and Healthcare Facility Licensure Program.
15. Submitted By (Print)
16. Title
17. Signature
18. Date
FOR STATE USE ONLY
Approved
ID Number
Signature
Date
Yes
No
CN-8 (formerly HFEL-4)
MAY 16
Page 2 of 2 Pages.
Page of 2