HUD-2576-hf-OHF Certificate for Need for Health Facility and Assurance o

Certificate of Need for
Health Facility and Assurance of
Enforcement of State Standards

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

OMB Approval No. 2502-xxxx (exp. xx/xx/xxxx)

Public reporting burden for this collection of information is estimated to average 0.20 hour per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The form is completed by FHA
Appraisers, Owners, and nonprofit entities for the Department of HUD to evaluate property as security for a long-term insured mortgage. This information is required to
obtain benefits. Section 232 of the National Housing Act authorizes mortgage insurance for the development of nursing homes and intermediate care facilities.
Provision of this information is required to obtain mortgage insurance benefits.
Privacy Act Statement. The United States Department of Housing and Urban Development (HUD), Federal Housing Administration, is authorized to solicit the
information requested in this form by virtue of Title 12, United States Code, Section 1701 et. seq., and regulations promulgated there under at Title 12, Code of Federal
Regulations. While no assurances of confidentiality are pledged to respondents, HUD generally discloses this data only in response to a Freedom of Information
Request. The agency may not collect this information and you are not required to complete this form unless it displays a currently valid OMB control number.

This Certificate covers the following type of facility: (check one)
(specify)

Hospital

Nursing Home

ICF

Other

To the Secretary of Housing and Urban Development: In accordance with the provisions of the National Housing Act, as amended,
and applicable portions of Titles VI, or XV, or XVI of the Public Health Service Act, this agency (name of agency)
____________________________________________________________________________________________________________________________________________________

certifies as follows:
1.

This facility will provide (types of services) __________________________________________________________________________________________________
without duplicating such services already adequately provided within the service area and without exceeding present needs
for such services in the area.

2.

In accordance with the approved State Health Plan and the State CoN requirements or Section 1122 (SSA) requirements, there
is a need for

(number of beds) __________________

to be located at
service area
3.

to be constructed and / or

(number of beds) ____________________________to

be modernized,

(address) ___________________________________________________________________________________________________________________ in

(name) ______________________________________________________________________________________________________________________

This HUD Certification of Need for service area stated above in the State of ______________________________________ is
issued in favor of

(name and address of Sponsor) __________________________________________________________________________________________ only,

for the construction and / or modernization of

(name and address of Project) _______________________________________________________

_____________________________________________________________________________________________________________________________________________

only, and is in effect for _______________________________ months from the date of issuance.
4.

There are in force in the State (or other political subdivision of the State in which the proposed project will be located) reasonable
minimum standards of licensure and methods of operation for this health facility.

5.

The prescribed standards of licensure and operation will be applied and enforced with respect to the applicant health facility.

6.

Amount of other Federal assistance, if any, $_________________________ from

(name of agency) _________________________________________

______________________________________________________________________________________________________________________________________________

7.

A copy of the State's approval under its CoN Program shall be attached.
X
Date Issued

Signature

Termination Date

Title

Name of Agency

Address and Phone Number of Agency

Clear All

Print

form HUD-2576-HF­OHF (5/2001)
ref. Handbook 4600.1