Form CN-6 "Project Application for an Adult Day Health Services Facility" - New Jersey

What Is Form CN-6?

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-6 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-6 "Project Application for an 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 AN 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 = $
In accordance with N.J.A.C. 8:43F-2.1(a)9., the owner(s) and administrator must obtain prior clearance from the Criminal Background
Investigation Unit (CBIU), of the Department of Health (DOH), prior to approval of the owner(s) application for licensure and prior to the
operation of the facility by the administrator.
Please be advised that incomplete applications will delay the review and approval process. A minimum of 60 days to review your
project application is required. You are not authorized to implement any portion of your proposal until you receive written
approval from the Certificate of Need and Health Care Facility Licensure Program.
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
8.
Number of licensed adult day health services slots requested:
__________
OWNERSHIP AND DISCLOSURE
9.
Identify 100% of the ownership, including the names and home addresses of all principals, (individuals or corporations owning
10% or more), and the percent owned by each. (For nonprofit facilities, provide the names and home addresses of the
members of the Board.) An attestation, signed by each individual listed below, that they have read the regulations at N.J.A.C.
8:43F and will comply with them must be included in the application package.
List any ownership interest(s) held by each person in any licensed health care facility in New Jersey or any other state. If
out-of-state facilities are owned, it is necessary to submit copies of letters from the respective state regulatory agencies
regarding the track records of those facilities with this application.
CN-6 (formerly HFEL-3)
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 AN 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 = $
In accordance with N.J.A.C. 8:43F-2.1(a)9., the owner(s) and administrator must obtain prior clearance from the Criminal Background
Investigation Unit (CBIU), of the Department of Health (DOH), prior to approval of the owner(s) application for licensure and prior to the
operation of the facility by the administrator.
Please be advised that incomplete applications will delay the review and approval process. A minimum of 60 days to review your
project application is required. You are not authorized to implement any portion of your proposal until you receive written
approval from the Certificate of Need and Health Care Facility Licensure Program.
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
8.
Number of licensed adult day health services slots requested:
__________
OWNERSHIP AND DISCLOSURE
9.
Identify 100% of the ownership, including the names and home addresses of all principals, (individuals or corporations owning
10% or more), and the percent owned by each. (For nonprofit facilities, provide the names and home addresses of the
members of the Board.) An attestation, signed by each individual listed below, that they have read the regulations at N.J.A.C.
8:43F and will comply with them must be included in the application package.
List any ownership interest(s) held by each person in any licensed health care facility in New Jersey or any other state. If
out-of-state facilities are owned, it is necessary to submit copies of letters from the respective state regulatory agencies
regarding the track records of those facilities with this application.
CN-6 (formerly HFEL-3)
MAY 16
Page 1 of 2 Pages.
PROJECT APPLICATION FOR AN ADULT DAY HEALTH SERVICES FACILITY
(CONTINUED)
Name of Facility
OWNERSHIP AND DISCLOSURE, Continued
9.
(Continued)
PROGRAM INFORMATION
10. How will the following services be provided? (Check all items that apply)
Occupational Therapy as per N.J.A.C. 8:43F-14.12
On site
Off site
Physical Therapy as per N.J.A.C. 8:43F-14.13
On site
Off site
Speech Therapy as per N.J.A.C. 8:43F-14.14
On site
Off site
Laundry as per N.J.A.C. 8:43F-14.16
On site
Off site
Meal Preparation as per N.J.A.C. 8:43F-14.11
On site
Off site
11. Days and Hours of Operation:
12. Number of Sessions:
13. Scaled architectural floor plans must be submitted, regardless of whether renovation/construction is required, with all rooms in
areas clearly labeled with dimensions and their proposed use.
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.
14. Submitted By (Print)
15. Title
16. Signature
17. Date
FOR STATE USE ONLY
Approved
ID Number
Signature
Date
Yes
No
CN-6 (formerly HFEL-3)
MAY 16
Page 2 of 2 Pages.
Page of 2