Certificate of Need (CON)

CON Forms

 
Please Note: Application format may not be altered or modified by an applicant.

 

Determinations of whether a project requires CON approval must be obtained in writing from the department. Please submit the appropriate form below to HSP for review:
 
Newspaper listing:
Prior to filing a CON, notice for 3 consecutive days must be placed in newspapers of substantial distribution to the location proposed.  A listing of these newspaper requirements can be found here

 

CON Determination Form Word PDF
CON Determination Form - Relocation Word PDF
 
 
If CON approval is required, applicant must complete:
  1. CON Main Form
  2. Supplemental Form (if indicated in table below)
  3. Financial Worksheet
Notice Regarding CON Filings:
Please be advised that Health Systems Planning (HSP) is in the process of revising its regulations (19-639-3(b)) to enable it to accept new CON filings through the CON Portal. While proceeding through this legal process of changing HSP’s regulations, HSP waives the requirement for Applicant(s) to file paper copies pursuant to Sec. 19a-639a-3.
 
Note: Should anyone not have the ability to file electronically, the present paper submission process may still be used. If you have any questions regarding a CON filing with HSP, please contact us at HSP@ct.gov or call us directly at (860) 418-7001.

 

1. CON Main Form

The Main Form must be completed by all applicants Word PDF
 

2. CON Supplemental Forms

The supplemental forms correspond to the circumstances listed in Conn. Gen. Stat. section 19a-638(a)(1)-(15) that require CON approval. Some supplemental forms serve more than one application type (e.g., termination of services).
 
Conn.Gen.
Stat.
Section
19a-
638(a)
Supplemental Forms
(1) Establishment of a new health care facility (mental health and/or substance abuse) -See note below* Word PDF
(2) Transfer of ownership of a health care facility -(excludes transfer of ownership/sale of hospital – see “Other” below) Word PDF
(3) Transfer of ownership of a group practice Word PDF
(4) Establishment of a freestanding emergency department Word PDF
(5)
(7)
(8)
(15)
Termination of a service:
  • Termination of inpatient or outpatient services offered by a hospital
  • Termination of surgical services by an outpatient surgical facility
  • Termination of an emergency department by a short-term acute care general hospital
  • Termination of inpatient or outpatient services offered by a hospital or other facility or institution operated by the state that provides services that are eligible for reimbursement under Title XVIII or XIX of the federal Social Security Act, 42 USC 301, as amended
Word PDF
(6) Establishment of an outpatient surgical facility Word PDF
(9) Establishment of cardiac services Word PDF
(10)
(11)
Acquisition of equipment:
  • Acquisition of computed tomography scanners, magnetic resonance imaging scanners, positron emission tomography scanners or positron emission tomography-computed tomography scanners
  • Acquisition of nonhospital based linear accelerators
Word PDF
(12) Increase in licensed bed capacityof a health care facility Word PDF
(13) Acquisition of equipment utilizing [new] technologythat has not previously been used in the state Word PDF
(14) Increase of two or more operating roomswithin any three-year period by an outpatient surgical facility or short-term acute care general hospital Word PDF
Other Transfer of Ownership / Sale of Hospital PDF
*This supplemental form should be included with all applications requesting authorization for the establishment of a mental health and/or substance abuse treatment facility. For the establishment of other “health care facilities,” as defined by Conn. Gen. Stat § 19a-630(11) - hospitals licensed by DPH under chapter 386v, specialty hospitals, or a central service facility - complete the Main Form only.

 

3. CON Financial Worksheet

The Financial workbook (Excel format) contains: (A) Non-Profit, (B) For-Profit and (C) Sale of Non-Profit Hospitals worksheets. Complete the appropriate worksheet based on the application type (19a-638(a) applications should complete financial worksheet (A) if a Non-Profit entity or (B) if a For-Profit entity. Applications for 19a-486a Sale of Non-Profit Hospitals should complete financial worksheet (C). Excel
 

Notification Forms

Equipment Replacement Form Word Pdf

 

CON Modification Form

CON ModificationForm Word Pdf

  

 
To download and print forms, you may need to download FREE Adobe Acrobat™ Reader 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.