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{"sheet":"Instructions","index":0,"n_rows":56,"n_cols":1,"rows_kept":56,"cut":false,"hidden":false,"merged":[[22,0,26,0],[27,0,28,0],[7,0,8,0]]}
["Annual Report"]
["Describing Each Affiliation with another Hospital or Hospital System"]
["Summary of Instructions"]
[]
["Connecticut General Statutes (C.G.S.) § 19a-486i (i), requires that each hospital and hospital system shall file with the Office of the Attorney General (\"OAG\") and the Office of Health Strategy (\"OHS\") a written report describing each affiliation with another hospital or hospital system.  "]
["The Annual Report must be filed with the OAG and with OHS no later than January 15th and annually thereafter."]
[]
["This file includes the spreadsheets needed to fulfill the Annual Reporting requirement.  There are two tabs (General Info and Affiliate Details) that all must be completed.  You may include additional \"Affiliate Details\" tabs for reporting on each affiliate listed on the General Info. tab.   Further instructions are provided on the individual tabs.   Filers are also required to submit an Adobe PDF version of their Annual Report.  Please take caution when converting the Excel File to PDF, make sure the \"Print Setting\" of the Excel file is set to \"Fit All Columns on One Page\" and the \"Print Area\" should be set to cover the full range of the data you have entered.  The file should be uploaded to the OHS Notification and Filings Web Portal located at:   https://ohsnotificationandfilings.ct.gov/Home/Index. "]
[]
[]
["Uploading your filing to the OHS Web Portal satisfies the requirement to make a joint filing"]
["with OAG and OHS."]
[]
["Key Definitions:"]
[]
["•“Affiliation” means the formation of a relationship between two or more entities that permits the entities to negotiate jointly with third parties over rates for professional medical services;"]
[]
["•“Hospital” has the same meaning as provided in section 19a-490 of the Connecticut General Statutes;"]
[]
["•“Hospital system” means: (A) A parent corporation of one or more hospitals and any entity affiliated with such parent corporation through ownership, governance or member ship, or (B) a hospital and any entity affiliated with such hospital through ownership, governance or membership;"]
[]
["•“Primary Service Areas” (“PSAs”) are defined by a set of postal ZIP codes. The Act defines PSA to mean “the smallest number of ZIP codes from which the Affiliate draws at least seventy-five per cent of its patients.”"]
["The Medicare.gov website was used for medical/physician specialties in the attached spreadsheets.  For the list of specialties and descriptions of each please refer to the Medicare.gov website by clicking on the link below: "]
[]
[]
[]
[]
["http://www.medicare.gov/physiciancompare/staticpages/resources/specialtydefinitions.html?AspxAutoDetectCookieSupport=1"]
[]
[]
[]
["Tab - General Info."]
[]
["1) Type in the Affiliate's Legal Name as registered with the State of Connecticut's - Office of the Secretary of State in column 2."]
["        "]
["2) Description of the nature of the relationship of the Hospital or Hospital System to the Affiliate (i.e., joint venture, subsidiary of a hospital or health system or independent from any hospital"]
["      or health system) in column 3."]
["       "]
["3) If within a hospital affiliated system, identify if owned directly by the hospital, in this case provide "]
["       the Hospital Name or if by a Health System Parent Corporation, provide that name in column 4."]
[]
[]
["Tab - Affiliate Details"]
[]
["1) Enter the  Affiliate Business Entity Legal Name  in column 2."]
[]
["   2) Affiliate Business Entity's Street Address entered in column 3."]
[]
["   3) Affiliate Business Entity's Town entered in column 4."]
[]
["   4) Affiliate Business Entity's ZIP Code entered in column 5."]
[]
["   5) Affiliate Business Entity's Primary Service Area (PSA) ZIP Code(s) entered in column 6."]
[]
["   6) A dropdown list for descripton of services at this location is provided in column 7.  If more than one service specialty is performed at the location then add an additional line for each service specialty."]
["      "]

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[]
["Affiliation Descriptions of Hospitals and Hospital Systems"]
["Written Report due by January 15th annually"]
[]
[null,"Date of Filing →","Date"]
[null,"Full Legal Name of Entity Reporting →","Full Legal Health System Name"]
[null,"Designated Contact Information →","Contact Name "]
[null,"(Title, Email, Phone)","Contact Information"]
[]
[]
[]
[-1,-2,-3,-4]
["Line","List all affiliates that meet the definition of an affiliate as defined in the instructions.","Address of each affiliate. (For Health Systems operating within CT, but headquartered outside of CT, List CT Business  only)","Describe the nature of the affiliation."]
[1,"Affiliate A","Affiliate A Address (Street, Town, CT ZIP Code-5 Digits)","The nature of the relationship among the parties to the affiliation"]
[{"$f":"A14+1","v":2},"Affiliate B","Affiliate B Address (Street, Town, CT ZIP Code-5 Digits)","The nature of the relationship among the parties to the affiliation"]
[{"$f":"A15+1","v":3},"Affiliate C","Affiliate C Address (Street, Town, CT ZIP Code-5 Digits)","The nature of the relationship among the parties to the affiliation"]
[4,"Affiliate D","Affiliate D Address (Street, Town, CT ZIP Code-5 Digits)","The nature of the relationship among the parties to the affiliation"]
[5,"Affiliate E","Affiliate E Address (Street, Town, CT ZIP Code-5 Digits)","The nature of the relationship among the parties to the affiliation"]
[6]
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[50]

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[]
["Affiliation Descriptions of Hospitals and Hospital Systems"]
["Written Report due by January 15th annually "]
[]
[null,"Date of Filing →",null,null,null,"Filing Date (mm/dd/yy)"]
[null,"Full Legal Name of Entity Reporting →",null,null,null,"Legal Name of Affiliate"]
[null,"Connecticut Parent Corp/Hospital Entity →",null,null,null,"Name of Hospital, Hospital System"]
[null,"Name of Specific Affiliate →",null,null,null,"Specific Affiliate being Reported"]
[]
["If more than one Affiliation is being reported in column 2 of the \"General Info.\" Tab, please follow the instructions below to add additional tabs. "]
[1,"Right click on the the \"Affiliate Details\" tab below."]
[2,"Click the \"Move or Copy\" option."]
[3,"Under the heading \"Before Sheet:,\"  click on \"(move to end)\"."]
[4,"Click inside the \"create a copy\" box."]
[5,"Click \"OK\"."]
[]
[-1,-2,"(3)",-4,-5,-6,-7]
["Line","Affiliate Name of each business entity that provides services as part of the affiliation. (For affiliates operating within CT, but headquartered outside of CT, List CT Business only)","Affiliate Business Entity Street Address (For affiliates operating within CT, but headquartered outside of CT, List CT Business only)","Affiliate Business Entity Town (For Affiliates operating within CT, but headquatered outside of CT, List CT Business only)","Business Entity ZIP Code (For affiliates operating within CT, but headquartered outside of CT, List CT Business only)","Primary Service Area (PSA) as defined in Section 19a-486i(a)(11), C.G.S (List PSA ZIP Codes separated by commas)","Description of services at this location"]
[null,null,null,null,null,null,"When user clicks into a cell below, a dropdown box appears to the right allowing the user to enter multiple services. Users must select 'one' service at a time when entering services. (If more than one service is provided at the business entity location please insert additional lines.)"]
[1,"Affiliate A Business Entity Legal Name ","Street Address","Town","Town ZIP Code","PSA Zip Code(s)","Surgical oncology"]
[2,"Affiliate A Business Entity Name                                                                                (Add rows if more than one service specialty is provided at the location)","Street Address","Town","Town ZIP Code","PSA Zip Code(s)","Radiation oncology"]
[3,"Affiliate B Business Entity Legal Name ","Street Address","Town","Town ZIP Code","PSA Zip Code(s)","General surgery"]
[4,"Affiliate B Business Entity Name                                                                                (Add rows if more than one service specialty is provided at the location)","Street Address","Town","Town ZIP Code","PSA Zip Code(s)","Interventional radiology"]
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{"sheet":"PhysicianSpecialities","index":3,"n_rows":73,"n_cols":1,"rows_kept":73,"cut":false,"hidden":true,"merged":[]}
["Addiction medicine"]
["Allergy/immunology"]
["Anesthesiologist Assistant"]
["Anesthesiology"]
["Audiologist"]
["Cardiac electrophysiology"]
["Cardiovascular disease (cardiology)"]
["Certified Nurse Midwife"]
["Certified Registered Nurse Anesthetist"]
["Chiropractic medicine"]
["Clinical Nurse Specialist"]
["Clinical Psychologist"]
["Clinical Social Worker"]
["Colorectal surgery (proctology)"]
["Critical care medicine (intensivists)"]
["Dermatology"]
["Diagnostic radiology"]
["Emergency medicine"]
["Endocrinology"]
["Family practice"]
["Gastroenterology"]
["General practice"]
["General surgery"]
["Geriatric medicine"]
["Gynecological oncology"]
["Hand surgery"]
["Hematology"]
["Hematology/oncology"]
["Hospice and palliative care"]
["Infectious disease"]
["Internal medicine"]
["Interventional pain management"]
["Interventional radiology"]
["Maxillofacial surgery"]
["Medical oncology"]
["Nephrology"]
["Neurology"]
["Neuropsychiatry"]
["Neurosurgery"]
["Nuclear medicine"]
["Nurse Practitioner"]
["Obstetrics/gynecology"]
["Occupational Therapy"]
["Ophthalmology"]
["Optometry"]
["Oral surgery (dentists only)"]
["Orthopedic surgery"]
["Osteopathic manipulative medicine"]
["Otolaryngology"]
["Pain management"]
["Pathology"]
["Pediatric medicine"]
["Peripheral vascular disease"]
["Physical medicine and rehabilitation"]
["Physical Therapy"]
["Physician Assistant"]
["Plastic and reconstructive surgery"]
["Podiatry"]
["Preventive medicine"]
["Primary care"]
["Psychiatry"]
["Psychiatry (geriatric)"]
["Pulmonary disease"]
["Radiation oncology"]
["Registered Dietitian / Nutrition Professional"]
["Rheumatology"]
["Sleep medicine"]
["Speech-Language Pathologist"]
["Sports medicine"]
["Surgical oncology"]
["Thoracic surgery"]
["Urology"]
["Vascular surgery"]