Form 2020 - Con Determination Form Relocation Of A Health Care Facility printable pdf download

Form 2020 - Con Determination Form Relocation Of A Health Care Facility

State of Connecticut

Office of Health Care Access

CON Determination Form

Relocation of a Health Care Facility

All persons who are requesting a determination from OHCA as to whether a CON is required

for their proposed relocation of a health care facility must complete this form. The completed

form 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 this proposal has more than two Petitioners, please attach a separate sheet, supplying the

same information for each Petitioner in the format presented in the following table.

Petitioner

Full Legal Name

Doing Business As

Name of Parent Corporation

Petitioner’s Mailing Address, if Post Office

(PO) Box, include a street mailing address

for Certified Mail

What is the Petitioner’s Status:

P for profit and

NP for Nonprofit

Contact Person at Facility, including

Title/Position:

This Individual at the facility will be the

Petitioner’s Designee to receive all

correspondence in this matter.

Form 2020 - Con Determination Form Relocation Of A Health Care Facility