In Connecticut, hospitals and other health care organizations must comply with statutes and regulations pertaining to the addition or discontinuation of facilities, services and certain medical equipment. OHCA provides applications and reporting formats for various types of required information.

Forms and formats for Certificate of Need (CON) applications are included here for informational purposes only. No CON application will be considered until a completed Letter of Intent is on file with OHCA. Health care facilities intending to pursue a CON application are encouraged to contact OHCA Certificate of Need Unit by telephone at (860) 418-7001 for information and applications specific to the anticipated project. Some forms are currently in Adobe Acrobat fillable PDF format.

To download and print forms, you need to get the FREE Adobe Acrobatâ„¢ Reader 6.0 and install it on your computer. Adobe also provides resources designed to help people with visual disabilities access the Adobe Portable Document Format. If you are unable to access these forms for any reason, you may request a paper copy from the agency.

Certificate of Need Application Forms*          

Instructions for CON Exemption Application

 MS-Word

CON Exemption Application (2010)

 MS-Word

Instructions for CON Determination

CON Determination (2020)

PDF

 MS-Word

Instructions for Letter of Intent

PDF

Letter of Intent (2030)

PDF

 MS-Word

Request Seeking a CON Waiver of Replacement Equipment Form 2040 with Instructions

Instructions for Certificate of Need Application

PDF

Certificate of Need Modules (2000)

PDF

 MS-Word

Certificate of Need Modules - Financial Projections

MS-Excel

Instructions for Modification of Previously Authorized CON

           PDF

 MS-Word

Modification of Previously Authorized CON (2050)

                        

 MS-Word

* Affidavits are required for the CON forms

Exempt Facility Form

Pursuant to Section 19a-639a of the Connecticut General Statutes, 11 categories of agencies are exempt from CON but must file annually with OHCA.

Exempt Facility Registration Form

 MS-Word

*Required Affidavits

Waiver/Exception Affidavit

PDF

 MS-Word

General Affidavit

PDF

 MS-Word

Hospital Affidavit

PDF

 MS-Word

PAO1-4 Affidavit

PDF

 MS-Word

Filing Fee Schedule

Request for New CON

PDF

 MS-Word

Request for Modification of Previous CON

PDF

 MS-Word

Freedom of Information Request Forms

FOI Request Form

PDF

 MS-Word
Hospital Inpatient Discharge Data Request Form

PDF

 MS-Word

May be used by persons wishing to request information from OHCA under the Freedom of Information Act.

State of Connecticut Forms                       

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