State of Connecticut
Office of Health Care Access
CON Determination Form
Form 2020
All persons who are requesting a determination from OHCA as to whether a CON is required
for their proposed project must complete this Form 2020. 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
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.