Form 2020 - Con Determination Form Relocation Of A Health Care Facility Page 2

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7/23/15
Contact Person’s Mailing Address, if PO
Box, include a street mailing address for
Certified Mail
Contact Person’s Telephone Number
Contact Person’s Fax Number
Contact Person’s e-mail Address
SECTION II. INFORMATION ON PROPOSED RELOCATION
Please provide a description of the proposed relocation, highlighting each of its important
aspects, on at least one, but not more than two separate 8.5” X 11” sheets of paper. At a
minimum each of the following elements need to be addressed, if applicable.
Name of the Health Care Facility:
Current Location:
Proposed Location:
Current Population Served:
Proposed Population Served:
Current Payor Mix:
Proposed Payor Mix:
Any other information that the Petitioner deems relevant:
Form 2020
Revised 08/11

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