New Freestanding Clinic 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
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 Operating Certificate.
4 If the building is leased, a copy of the lease.
5 Annual Visits / Procedures projected as part of the Certificate of Need (CON) process Total Annual Visits Total Annual Medicaid Fee-for-Service Visits
6 Provider Type ==>   Refer to Grouping per NYCRR Part 86-4.13
7 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) Useful
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