New Freestanding Clinic Form
| New providers are required to submit the following: | |||||
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| 1 | Cover letter providing the details of the request, signed by the provider´s CEO/CFO and addressed to => | Monique Grimm Director Bureau of Hospital & Clinic Rate Setting One Commerce Plaza, Room 1432 99 Washington Avenue Albany, New York 12210 |
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| 2 | Copy of the Certificate of Need (CON) approval letter issued by the Division of Health Facility Planning. For copies or questions email: cons@health.ny.gov | ||||
| 3 | Copy of the Operating Certificate. | ||||
| 4 | If the building is leased, a copy of the lease. | ||||
| 5 | Annual Visits / Procedures projected as part of the Certificate of Need (CON) process | Total Annual Visits | Total Annual Medicaid Fee-for-Service Visits | ||
| 6 | Provider Type ==> | Refer to Grouping per NYCRR Part 86-4.13 | |||
| 7 | Itemized details of the Total CON-approved capital costs. Note: Complete all applicable information. All items may NOT apply to your facility. |
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| CON Approved Capital Costs ($ Value) | Useful Life of the Asset |
Depreciation / Amortization per Year | |||
| a. | Rent (if the building is leased) | ||||
| b. | Building | ||||
| c. | Renovation & Demolition | ||||
| d. | Construction Contingency | ||||
| e. | Architect / Engineering Fees | ||||
| f. | Other Fees | ||||
| g. | Moveable Equipment | ||||
| h. | Financing Costs | ||||
| i. | Interim Interest Expense | ||||
| j. | CON Fees | ||||
| Total Project Cost approved per the CON application |
$0 |
$0 |
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