Delaware Certificate of Public Review

Certificate of Public Review Application Kit

State of Delaware

Delaware Health Resources Board

Bureau of Health Planning and Resources Management

Delaware Division of Public Health

Adopted: April 13, 1995

Effective:

Updated: July 15, 1996

Updated: June 28, 1999

Updated: December 30, 1999

Updated: May 15, 2002

Updated: February 23, 2006

Updated: July 5, 2007

Updated: December 3, 2008

Updated: August 5, 2009

Attachment I - Notice of Intent

NOTICE OF INTENT (CERTIFICATE OF PUBLIC REVIEW)

1. Name of Applicant:

2. Address:

3. Telephone: Fax: Email:

4. Person to Contact:

5. Type of Ownership:

Public

Private Non-profit

Proprietary (Individual)

Proprietary (Partnership)

Proprietary (Corporation)

6. Anticipated Date of Filing Application:

7. Estimated Capital Expenditure: $

8. Please attach a brief Narrative (one page or less if possible) which describes the project.

9. STATEMENT OF CERTIFICATION:

The statements and information provided herein are true and correct to the best of my knowledge and belief.

Attachment II - Certificate of Public Review Application

CERTIFICATE OF PUBLIC REVIEW APPLICATION

The purpose of this application is to obtain the information necessary to make a determination of need pursuant to Title XVI, Chapter 93 of the Delaware Code.

The application contains three (3) sections: A. Background Information; B. Review Considerations; C. Schedules.

STATEMENT OF CERTIFICATION:

The statements and information provided in this Certificate of Public Review Application are true and correct to the best of my knowledge and belief.

A. Background Information

1. Name of Applicant:

2. Address:

3. Telephone: Fax: Email:

4. Person to Contact:

5. Please attach a list of all officers and members of the governing board.

6. If acquisition of real estate is involved, attach relevant agreements and zoning documentation.

7. Does the Applicant have a contract with Blue Cross and Blue Shield of Delaware?

Yes No

If not, do you intend to seek?

Yes No

8. Has the Applicant retained a firm that provides overall management services on a contract basis?

Yes No

If yes, please describe:

9. Please attach a Schedule of Implementation.

10. Please include a copy of most recent annual audited financial statements.

11. Does the Applicant have a long-range plan?

Yes No

B. Review Considerations

Please provide a narrative describing the project in as much detail as the Applicant feels appropriate.

Conformity of Project with Review Criteria

Please discuss the conformity of the project with the Health Resources Management Plan.

Population's need for proposed services.

Are there alternative providers of this service readily accessible to the user population?

Yes No

Relationship to the existing health care delivery system.

Project's effect on quality of health care.

C. Schedules

Schedule 1 - Project Elements

Schedule 2 - Objectives of This Proposal

Schedule 3 - Program Change

Schedule 4 - Statement of Revenues and Expenses

Schedule 5 - Source of Revenue

Schedule 6 - Bed Use Data

Schedule 7 - Changes in Staffing

Schedule 8 - Location of Beds by Floor/Building

Schedule 9 - Facility Change

Schedule 10 - Estimated Capital Expenditure

Schedule 11 - Sources of Financing

Schedule 12 - Indicators of Financial Feasibility

Schedule 13 - Debt Service Coverage

Schedule 14 - Present Long Term Debt

Schedule 15 - Detailed Equipment Listing

Attachment III - Documentation for Approval of Emergency Situation

DOCUMENTATION FOR APPROVAL OF “EMERGENCY SITUATION”

1. Name of Applicant:

2. Date of initial contact with the Bureau of Health Planning and Resources Management:

3. Please attach a brief statement describing the nature of the emergency situation.

4. Please attach a brief statement explaining how the emergency situation is proposed to be remedied, including estimated capital cost.

5. Was an architect, engineer, or other consultant retained to assist the Applicant?

Yes No

6. What is the expected date of completion of any necessary repairs?

7. Will the Applicant be filing a subsequent application to undertake more extensive capital expenditures to resolve this situation?

Yes No

8. STATEMENT OF AFFIRMATION:

The Signatory hereby affirms that the conditions affected by this Application represent an “Emergency Situation” which threatens the safety of patients and/or the ability of the health facility to remain in operation.

Submit all completed sections and attachments as required.