Fill and Sign the Letter Care Form

Letter of Intent Form 1. Brief Descriptive Title of Proposal: ____________________________________ _________________________________________________________________ 2. Information about the Applicant: Name: ____________________________________________________________ Address: ________________________________________________________ 3. Information About the Facility (if different from applicant): Name: ____________________________________________________________ Address: ________________________________________________________ 4. Information about the Chief Executive Officer: Name: ____________________________________________________________ Address: ________________________________________________________ Telephone: ______________________________________________________ E-Mail: __________________________ Fax Number: ____________________ 5. Information for the person to contact regarding this proposal: Name: ____________________________________________________________ Address: ________________________________________________________ Telephone: ______________________________________________________ E-Mail: __________________________ Fax Number: ____________________ 6. Brief Summary Description of Proposal: ________________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ 7. Capital Cost of Proposal: __________________________________________ 8. First Full Year Operating Cost of Proposal: ____________________________ 9. Month and year the proposal would be implemented: ____________ 10. Will you be requesting:  Expeditious review: Yes____ No____  Accelerated review: Yes____ No____ 11. Please place an ‘X’ next to each category that best describes the facility: ___ Hospital ___ Nursing facility ___ Inpatient rehabilitation center (including drug/alcohol treatment centers) ___ Freestanding ambulatory surgical center ___ Inpatient hospice ___ Other (specify) ___________ 12. Please place an ‘X’ next to the category that best describes the ownership of the facility. ___ non-profit ___ for-profit 13. Please check each and every category that describes this proposal. ____A. Construction, development or establishment of a new healthcare facility ____B. A capital expenditure for health care equipment in excess of $1,000,000. ____C. Construction or renovation of a health care facility in excess of $2,000,000. ____D. An acquisition by or on behalf of a health care facility or HMO by lease or donation _____E. Acquisition of an existing health care facility, if the services or the bed capacity of the facility will be changed, in the following ways:  change in bed capacity which increases the total number of beds. ____  change in bed capacity which redistributes beds among discrete services (e.g., obstetrics, pediatrics, medical, surgical) or levels of care (e.g., intensive coronary, special, post acute, skilled nursing, intermediate, rehabilitative) or relocates beds from one physical facility or site to another by ten (10) beds or 10%, whichever is less, in any two year period. ______  the addition of a health service not provided in or through the facility throughout the previous twelve (12) months. _____  the termination of a health service provided in or through the facility. _____  any capital expenditure which results in an increase in bed capacity of a hospital and inpatient rehabilitation centers (including drug and/or alcohol abuse treatment centers). ______  any capital expenditure which results in an increase in bed capacity of a nursing facility in excess of 10 beds or 10% of facility’s licensed bed capacity, which ever is greater. ______  the offering of a new health service with annualized costs in excess of $750,000 _______  predevelopment activities not part of a proposal, but which cost in excess of $2,000,000. ______  establishment of an additional inpatient premise of an existing inpatient health care facility _______  tertiary or specialty care services _______ 14. For each single piece of healthcare equipment in excess of $1,000,000, provide the following: Type Manufacturer’s Name Model Name and No. Cost _______ _____________________ _________________________ __________ _______ _____________________ _________________________ __________ _______ _____________________ _________________________ __________ _______ _____________________ __________________________ __________ 14. Please indicate the financing mix for the capital cost of this proposal Source Amount Percent Interest Rate Terms (years) Equity 1 Debt Lease TOTAL 15. Will zoning approval be required as part of this proposal: Yes ____ No ____ 16. Will this proposal involves new construction or expansion of patient occupancy, that will require an approved plan for water supply and sewage disposal from the state and/or municipal authority: Yes ___ No ___ I hereby certify that the information contained in this form is complete, accurate and true as of this (date). ________________________________________________ President or Chief Executive Officer 1 Equity means non-debt funds contributed towards the capital cost of an acquisition or project which are free and clear of any repayment obligation or liens against assets, and that result in a like reduction in the portion of the capital cost that is required to be financed or mortgaged.