Office Of Health Care Access Form For Modification Of A Previously Authorized Certificate Of Need (Page 2 of 4) in pdf

Office Of Health Care Access Form For Modification Of A Previously Authorized Certificate Of Need Page 2

Page 2 of 4

SECTION II. GENERAL PROPOSAL INFORMATION

Title of Previously Authorized Project and Associated Docket Number(s):

________________________________________________________________

Location of proposal (Town including street address):

________________________________________________________________

Type of Modification Request:

Change in the Scope of the Authorized Certificate of Need Project

Extension of CON Expiration Date

Change in a CON Order Condition

(other than to extend expiration date)

Other – Describe: ______________________________________________

SECTION III. IF REQUESTING A CHANGE IN THE SCOPE OF AUTHORIZED PROJECT:

Provide a one page description of the requested change in the scope of a previously

authorized Certificate of Need project and provide a detailed rationale for such change:

SECTION IV. IF REQUESTING AN EXTENSION OF THE CON EXPIRATION DATE:

Certificate of Need expiration date per CON Final Decision: ________________

Requested revised CON expiration date: _______________________________

Rationale for increased time to fully complete and implement the authorized project:

________________________________________________________________

Revised 8/11

Office Of Health Care Access Form For Modification Of A Previously Authorized Certificate Of Need Page 2