New Freestanding Ambulatory Surgery Center Form

  • Form is also available in the following formats: (XLSX) - (PDF)
New 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
Director
Bureau of Hospital & Clinic Rate Setting
One Commerce Plaza, Room 1432
99 Washington Avenue
Albany, New York 12210
2 Copy of the Operating Certificate.
3 Annual Visits / Procedures projected as part of the Certificate of Need (CON) process Total Annual Medicaid Fee-for-Service Visits