Capital Rate Appeal Information

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Providers are required to submit the following:
1 Cover letter providing the details
of the request, signed by the
provider's CEO/CFO and addressed to =>
Monique Grimm
Bureau of Hospital & Clinic Rate Setting
One Commerce Plaza, Room 1432
99 Washington Avenue
Albany, New York 12210
2 Copy of the Certificate of Need (CON) approval letter issued by the Division of Health Facility Planning. For copies or questions email:
3 Copy of the project completion and building occupancy letter issued by the regional Department of Health office after the site visit.
4 Annual Visits / Procedures projected as part of the Certificate of Need (CON) process Total Annual
Total Annual
Medicaid Fee-for-Service
5 Itemized details of the Total CON-approved capital costs.
Note: Complete all applicable information. All items may NOT apply to your facility.
    CON Approved
Capital Costs
($ Value)
Life of the Asset
Depreciation / Amortization
per Year
a. Rent (if the building is leased)      
b. Building      
c. Renovation & Demolition      
d. Construction Contingency      
e. Architect / Engineering Fees      
f. Other Fees      
g. Moveable Equipment      
h. Financing Costs      
i. Interim Interest Expense      
j. CON Fees      
  Total Project Cost approved per the CON application $0   $0