MDCH - Electronic Forms

The following electronic forms are available for filing letters of intent, applications, emergency applications, amendments, and required progress reports for approved projects. The Department encourages online filing of letters of intent, nonsubstantive, substantive, and emergency applications, and amendments through the CON E-Serve system (applications subject to comparative review must be filed in paper format).

For paper filings or paper forms still required with an electronic filing, please download the required form each time you need to use it. Outdated forms will not be accepted.

Special Notices:

A letter of intent must be submitted and processed separately prior to filing an application.

The Department no longer requires a separate certification form to be submitted with each application. Applicants are now required to confirm their certification and agreement to abide by the applicable Project Delivery Requirements in their direct responses to each assigned standard. Applicants filing paper applications should respond, as online filers do, by stating after each applicable Project Delivery Requirement section with the following statement, "As the authorized agent, I certify that the applicant will abide by the agreements and assurances required by this Section."

Form No.	Title
	Supplemental Finance Information (Revised 1/06)
	Metro, Micro Statistical, and Rural Counties
CON-004	Non-Substantive Routing Record - 12/08
CON-005	Substantive Routing Record - 03/11
CON-100	Application for CON - All Applicants - 1/11
CON-100- Instructions	Application Information and Instructions - 6/08
CON-101	Application for Emergency Certificate of Need - 2/07
CON-105	Project Summary - 12/08
CON-110-A	Acquisition of Licensed Health Facility - 9/06 (Also use CON-100 and CON-110-F.)
CON-110-B	Bed Replacement/Relocation Report - 9/06 (Also use CON-100 and CON-110-F.)
CON-110-C	Mobile Host Site - 8/06 (Also use CON-100 and CON-110-F.)
CON-110-D	Acquisition, Replacement or Relocation of a Covered Clinical Service - 5/08 (Also use CON-100 and CON-110-F.)
CON-110-F	Finance Report - 1/09
CON-110-i	Application for Change in Mobile Host Site - 7/07
CON-113	Application for Swing Beds - 2/07
CON-144	Amended Request for CON - 3/08
CON-145	Effective Dates of Standards - 11/11
CON-148	Projects Eligible for Non-Substantive Review - 12/10
CON-149	Letter of Intent - 6/08 (Online LOI via Single Sign-on)
CON-200	Section 22225 Excerpts of PA 368 of 1978 - 01/09
CON-200-A	Review Standards Instructions - 2/07
CON-202	Lithotripsy Standards - 02/25/08
CON-204	NICU Standards - 08/12/10
CON-205	Psychiatric Beds Inpatient Standards - 11/05/09
CON-206	Surgical Standards - 06/20/08
CON-208	Open Heart Surgical Standards - 02/25/08
CON-209	Heart/Lung/Liver Transplant Standards - 05/28/10
CON-210	Cardiac Catheterization Standards - 02/25/08
CON-210-B	Request for Change to Interventional Cardiologist
CON-210-C	Historical Utilization Report AMI Cases Eligible for Primary PCI
CON-210-D	Historical Utilization Report Interventional Cardiologist Cases
CON-211	MRT Standards - 11/21/11
CON-212	CT Scanner Standards - 06/20/08
CON-213	MRI Standards - 11/21/11
CON-214	Hospital Beds Standards - 3/02/09
CON-217	NH-HLTCU Bed Standards - 03/11/11
CON-217-A	NH-HLTCU Certification Report - 9/08
CON-217-B	NH-HLTCU Culture Change Model Worksheet - 03/11
CON-219	Physician Commitment for MRI - 11/11
CON-220	Physician Commitment for MRI Procedures - 11/08
CON-220-A	Certification for Referring Doctor Commitment of Available MRI Adjusted Procedures - 8/06
CON-222	OH Surgery Utilization Report - 12/10
CON-226	Pancreas Transplantation Standards - 11/05/09
CON-227	PET Scanner Standards - 11/21/11
CON-228	Air Ambulance Standards - 08/12/10
CON-229	Bone Marrow Transplantation Standards - 12/03/10
CON-230-A	Lithotripsy Data Release Authorization - 3/08
CON-300	Project Description - 2/07
CON-600	Project Personnel Need - 2/07
CON-602	MRT Staffing Report - 2/06
CON-700	Inpatient Bed Utilization Report - 8/06
CON-704	Surgical Utilization Report - 11/06
CON-704-A	Surgical Physician Commitment - 9/06
CON-706	CT Utilization Report - 5/08
CON-706-A	CT Physician Commitment - 5/08
CON-707	MRT Utilization Report - 9/06
CON-707-A	MRT Governing Body Resolution - 11/11
CON-715	Lithotripsy Utilization Report - 8/06
CON-716	Cardiac Catheterization Utilization Report - 1/11
CON-720	Hospice Days of Care Report - 2/07
CON-732-A	PET Utilization Report - 11/11
CON-733	PET Data Verification - 3/07
CON-733-A	PET Sample of Governing Body Resolution for Withdrawal of Data Commitments - 11/11
CON-733-B	PET Withdrawal of Data Commitments - 11/11
CON-800	Physical Design Project Report - 2/07
CON-801	Facility Area Report - 2/07
CON-802	LTC Physicial Design Report - 2/07
CON-803	Facility Area Report LTC - 2/07
CON-804	Physical Design Report - 2/07
CON-1000	Equipment Report - 2/07
CON-1001	Major Equipment Report - 3/08
CON-1100	General Financing Questions - 1/09
CON-1105	Grants and Appropriations - 2/07
CON-1108	Hospital Utilization Statistics - 2/07
CON-1110	Hospital 5-Year Revenue & Expense Report - 2/07
CON-1114	NH Statement Revenue and Expense - 2/07
CON-1118	Revenue and Expense Statement Other - 2/07
CON-1200	Financed Projects - 2/09
CON-1202	Debt Service Coverage - 2/07
CON-1203	Amortization - 2/07
CON-1300	Project Implementation Progress Report - 10/10

Share this link: