DPH: OHCA Forms

{Office of Health Care Access}
 
 OHCA Forms
 
In Connecticut, hospitals and other health care organizations must comply with statutes and regulations pertaining to the establishment or termination of facilities, services and certain medical equipment. OHCA provides applications and reporting formats for various types of required information.
 
Please Note: Application format may not be altered or modified by an applicant.
 
Determinations of whether a project requires CON approval must be obtained in writing from the department. Please submit the appropriate form below to OHCA for review:


Important

CON PORTAL

  • ALL CON related material (Applications, Determinations, & Modifications) should be filed through the CON Portal.  To register and submit, click here: http://dphconwebportal.ct.gov/
  • The $500 CON Fee should also be filed with OHCA at the time of the submission of the CON Application, using MasterCard or Visa, through the CON Portal.
Please review the CON Portal User Guide

To view the status of CONs submitted through the portal, please visit our new reporting site: https://dphconwebportal.ct.gov/Report  -No registration is required to view CON Status Reports.

Any questions, please contact Steven Lazarus or Chris Wyvill at ohca@ct.gov or (860) 418-7001
 

 
CON Determination Form
CON Determination Form - Relocation
 
 
If CON approval is required, applicant must complete:
  1. CON Main Form
  2. Supplemental Form (if indicated in table below)
  3. Financial Worksheet
Notice Regarding CON Filings:

Please be advised that the Office of Health Care Access (OHCA) is in the process of revising its regulations (19-639-3(b)) to enable it to accept new CON filings through an electronic media, either filed via email to OHCA@ct.gov or through use of a USB.
While proceeding through this legal process of changing OHCA’s regulations, OHCA waives the requirement for Applicant(s) to file paper copies pursuant to Sec. 19a-639a-3. All new CON Applications filed electronically with OHCA should be on a USB or via OHCA@ct.gov with the following:
a) A scanned copy of each submission in its entirety, including all attachments, properly executed and notarized where necessary, in Adobe (.pdf) format.
b) An electronic copy of the applicant’s responses in MS Word (the applications) and MS Excel (the financial attachment).

Note: Should anyone not have the ability to file electronically, the present paper submission process may still be used.
If you have any questions regarding a CON filing with OHCA, please contact us at OHCA@ct.gov or call us directly at (860) 418-7001.
 
1. CON Main Form
 
The Main Form must be completed by all applicants
 
2. CON Supplemental Forms
 
The supplemental forms correspond to the circumstances listed in Conn. Gen. Stat. section 19a-638(a)(1)-(15) that require CON approval. Some supplemental forms serve more than one application type (e.g., termination of services).
 
Conn.
Gen.
Stat.
Section
 19a-
638(a)
Supplemental Forms
(1)
 Establishment of a new health care facility (mental health and/or substance abuse) - See note below*
(2)
 Transfer of ownership of a health care facility - (excludes transfer of ownership/sale of hospital – see “Other” below)
(3)
 Transfer of ownership of a group practice
(4)
 Establishment of a freestanding emergency department
(5)
(7)
(8)
(15)
 Termination of a service:
  • Termination of inpatient or outpatient services offered by a hospital
  • Termination of surgical services by an outpatient surgical facility
  • Termination of an emergency department by a short-term acute care general hospital
  • Termination of inpatient or outpatient services offered by a hospital or other facility or institution operated by the state that provides services that are eligible for reimbursement under Title XVIII or XIX of the federal Social Security Act, 42 USC 301, as amended
(6)
 Establishment of an outpatient surgical facility
(9)
 Establishment of cardiac services
(10)
(11)
 Acquisition of equipment:
  • Acquisition of computed tomography scanners, magnetic resonance imaging scanners, positron emission tomography scanners or positron emission tomography-computed tomography scanners
  • Acquisition of nonhospital based linear accelerators
(12)
 Increase in licensed bed capacity of a health care facility
(13)
 Acquisition of equipment utilizing [new] technology that has not previously been used in the state
(14)
 Increase of two or more operating rooms within any three-year period by an outpatient surgical facility or short-term acute care general hospital
    
Other
 Transfer of Ownership / Sale of Hospital
*This supplemental form should be included with all applications requesting authorization for the establishment of a mental health and/or substance abuse treatment facility. For the establishment of other “health care facilities,” as defined by Conn. Gen. Stat § 19a-630(11) - hospitals licensed by DPH under chapter 386v, specialty hospitals, or a central service facility - complete the Main Form only.
 
3. CON Financial Worksheet
 
The Financial workbook (Excel format) contains: (A) Non-Profit, (B) For-Profit and (C) Sale of Non-Profit Hospitals worksheets. Complete the appropriate worksheet based on the application type (19a-638(a) applications should complete financial worksheet (A) if a Non-Profit entity or (B) if a For-Profit entity. Applications for 19a-486a Sale of Non-Profit Hospitals should complete financial worksheet (C). Excel
 
 
Notification Forms
 
   
Equipment Replacement Form
Group Practice Filing Instructions
Group Practice Filing Forms                             
 

CON Modification Form
   
CON Modification Form                                      

Freedom of Information Request Forms

FOI Request Form


Hospital Inpatient Discharge Data Request Form


MS-Word

 

May be used by persons wishing to request information from OHCA under the Freedom of Information Act.

State of Connecticut Forms                       

{CLIC Logo}

Complete listing of State of Connecticut Licenses and Forms                          


 
 
 
To download and print forms, you may need to download FREE Adobe Acrobat™ Reader and install it on your computer. Adobe also provides resources designed to help people with visual disabilities access the Adobe Portable Document Format. If you are unable to access these forms for any reason, you may request a paper copy from the agency.




Content Last Modified on 12/11/2017 11:18:53 AM