Standard Application

(1) Application for a certificate of need shall be made on form(s) provided by the Commission. The applicant must provide all information requested in the application forms. The information which may be required in the application form(s) includes, but is not necessarily limited to, the following: (a) Facility identification, including legal interests and status, operator and owners; (b) Detailed project description; (c) Detailed project cost data; (d) Project operating costs and revenues, patient charges, and occupancy rate; (e) Information on whether the proposed project will provide health care that meets appropriate quality standards; (f) Information on the project’s relationship to public needs and the existing health service system; and (g) A copy of any signed agreement between the applicant and TennCare managed care organizations; if a signed agreement has not been executed prior to the Commission’s consideration of the application, the applicant shall provide a list of any such organizations with whom the applicant is negotiating, or a statement that the applicant does not intend to contract with any TennCare managed care organization(s). (2) The accuracy of the information provided must be attested to by the responsible party or his agent in a notarized statement. Providing false, incorrect, misleading, or fraudulent information is grounds for revocation of the certificate of need.