HUD-92576-OHF Certificate for Need for Health Facility and Assurance o

Certificate of Need (CON) for Health Facility and Assurance of Enforcement of State Standards Section 242

U.S. Department of Housing and Urban Development Office of Hospital Facilities

OMB Approval No. 2502-0602 (Exp. 08/31/2019)

Public reporting burden for this collection of information is estimated to average 2 hours. This includes the time for collecting, reviewing, and reporting the data. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Reports Management Officer, QDAM, U.S. Department of Housing and Urban Development, Washington, DC 20410-5000. Do not send this completed form to the above address. The information requested is required to obtain the benefit under Section 242 of the National Housing Act. No confidentiality is assured. The information is being collected to obtain the supportive documentation which must be submitted to HUD for approval, and is necessary to ensure that viable projects are developed and maintained. The Department will use this information to determine if properties meet HUD requirements with respect to development, operation and/or asset management, as well as ensuring the continued marketability of the properties. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. 

Warning: Federal law provides that anyone who knowingly or willfully submits (or causes to submit) a document containing any false, fictitious, misleading, or fraudulent statement/certification or entry may be criminally prosecuted and may incur civil administrative liability. Penalties upon conviction can include a fine and imprisonment, as provided pursuant to applicable law, which includes, but is not limited to, 18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802; 24 C.F.R. Parts 25, 28 and 30, and 2 C.F.R. Parts 180 and 2424.

This Certificate covers the following type of facility: (check one):     
Hospital		Other (Specify):
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 ________________________ certifies as follows: 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. In accordance with the approved State Health Plan and the State CON requirements or Section 1122 (SSA) requirements, there is a need for __________ of beds to be constructed and/or __________ of beds to be modernized, to be located at _________________________________________________________(address) in service area ________________________________. This HUD CON 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. 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 of this health facility. The prescribed standards of licensure and operation will be applied and enforced with respect to the applicant health facility. Amount of other Federal assistance, if any, $_______________ from ____________________________ ____________________________(name of agency). A copy of the State’s approval under its CON Program shall be attached.
Date Issued (mm/dd/yyyy)	Signature
Termination Date:	Title
Name of Agency:	Address and Phone Number of Agency

Previous versions obsolete	Page 0 of 1	form HUD-92576­OHF