Office Of Health Care Access Form For Modification Of A Previously Authorized Certificate Of Need
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4State of Connecticut
Office of Health Care Access
Form for Modification of a Previously
Authorized Certificate of Need
All persons who are requesting a modification to a previously authorized Certificate of Need
must complete this form. Completed forms should be submitted to the Director of the Office of
Health Care Access, 410 Capitol Avenue, MS#13HCA, P.O. Box 340308, Hartford,
Connecticut 06134-0308.
SECTION I. PETITIONER INFORMATION
If more than 2 Petitioners, please attach a separate sheet of paper and provide additional
information in the format below:
Petitioner
Petitioner
Full legal name
Doing Business As
Name of Parent Corporation
Mailing Address, if Post
Office Box, include a street
mailing address for Certified
Mail
Petitioner type (e.g., P for
profit and NP for Not for
Profit)
Name of Contact person,
including title
Contact person’s street
mailing address
Contact person’s phone, fax
and e-mail address
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