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

Certificate of Need (CON) 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. 11/30/2022)

Public Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.  Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  The information requested is required in order to receive the benefits to be derived. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Housing and Urban Development, Office of the Chief Data Officer, Attention: Departmental Clearance Officer, 451 7^th Street SW. Room, Washington, DC 20410 or email [email protected].  HUD collects this information, pursuant to Section 242 of the National Housing Act and regulations at 24 CFR Part 242, in order to review Section 242 applications to determine eligibility, underwrite insured hospital loans, ensure adequate collateral, process initial/final endorsement, manage FHA’s hospital portfolio, monitor and manage risk, and ensure ongoing compliance with regulations. No confidentiality is assured.

Warning: Any person who knowingly presents a false, fictitious, or fraudulent statement or claim in a matter within the jurisdiction of the U.S. Department of Housing and Urban Development is subject to criminal penalties, civil liability, and administrative sanctions.

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. 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