Mississippi State Department of Health s3

MISSISSIPPI STATE DEPARTMENT OF HEALTH

NOTICE OF INTENT TO APPLY FOR A CERTIFICATE OF NEED (Must be received 30 days prior to submission of a CON application)

TITLE OF PROJECT: Type of Review: ( ) Quarterly ( ) Expedited ( ) Unknown

I. APPLICANT/FACILITY INFORMATION

APPLICANT Applicant Legal Name: d/b/a (if applicable): Address: City: State: Zip Code: County: Telephone: Parent Organization (if applicable): E-mail Address: Fax: PRIMARY CONTACT PERSON Name: Title or Position: Firm: Address: City: State: Zip Code: Telephone: Fax: E-mail Address: LEGAL COUNSEL /CONSULTANT(if applicable) Name: ( )Counsel ( ) Consultant Firm: Address: City: State: Zip Code: Telephone: Fax: E-mail Address:

FACILITY (if different from Applicant) Name: Address: City: State: Zip Code: County: Telephone:

1. Select the type of ownership of present or proposed facility.

Mississippi State Department of Health Form No. 802 E Page 1 of 3 Revised 8-05-09 Health Planning & Resource Development State of IncorporationorOrganization: II. PROJECT DESCRIPTIONII. 2. Page State Mississippi Department Health of 4. 3. 2. 1. TAX PAYING TAX EXEMPT Does theDoesproject involve correctionof code or Licensuredeficiencies? a Provide justificationbrief fortheproject. involved areas construction, new of location including project, the of description narrative a Provide 2 of Estimatedproject costs: 3 in in repairrenovation, or newservices beingproposed, equipmentand/oracquisition proposed. Identify any changesproposed bed (increases/decreases)by licensurecategory. Revised 8-05-09 TotalEstimated ProjectCost OtherCosts(specify) Capitalized Interest Contingency Reserve Fees(architectural, etc.consultant, Site Preparation Cost Land Cost Total EquipmentNon-Fixed Cost TotalEquipment CostFixed minor (i.e. paintingand repairs,refurbishing) Cost Improvement Capital ConstructionCost– Renovation ConstructionCost– New General Partnership Public (Hospital or Government) Not-for-Profit Corporation or Limited Partnership Limited Liability Partnership b. a. deficiencies. licensure or code of correction involve not do which components project any List Ifyes, are deficienciesall corrected this by project? No. 802 Form E Limited Liability Company Corporation Business $ Health Resource Planning & Development Sole Proprietor . 5. Approximate: (a) project starting date ______(b) project completion date ______

Submitted by: ______Signature

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Mississippi State Department of Health Form No. 802 E Page 3 of 3 Revised 8-05-09 Health Planning & Resource Development