New Freestanding Clinic Form

• Form is also available in the following formats: (XLSX) - (PDF)

New providers are required to submit the following:
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
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.
		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