ࡱ> c Tbjbj 3ff5S5_&_&_&_&_&D&&&#')&ʇs-@| A A AAB"cBwB $p_&tEABABtEtE_&_& A A4 I I ItEF_& A_& A1h ItE I Iz` AMEj~\0ʇ]~|($F((_&0BMC ICtQD#BBBHBBBʇtEtEtEtE(BBBBBBBBB %%:  Schedule 17 CON Forms Specific to Diagnostic and Treatment Centers Article 28 Contents: Schedule 17 A - D&TC Program Information Schedule 17 B - D&TC Community Need Schedule 17 C - Impact of CON Application on D&TC Operating Certificate Schedule 17 A - Diagnostic and Treatment Center Program Information. See Schedules Required for Each Type of CON to determine when this form is required. Instructions: In the space below, briefly indicate how the facility intends to comply with state and federal regulations. If the application involves conversion of an existing practice, state who owns the practice and how the conversion will be done. If there are other entities utilizing the same space or resources, please state exactly how the space and resources will be allocated. Also, provide a description of the other entities.  FORMTEXT       For D&TC -Ambulatory Surgery Projects: Please provide a list of ambulatory surgery categories you intend to provide. List of Proposed Ambulatory Surgery Category FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       For D&TC -Ambulatory Surgery Projects: Please provide the following information: Number and Type of Operating Rooms: Current:  FORMTEXT       To be added:  FORMTEXT       Total ORs upon Completion of the Project:  FORMTEXT       Number and Type of Procedure Rooms: Current:  FORMTEXT       To be added:  FORMTEXT       Total Procedure Rooms upon Completion of the Project:  FORMTEXT       Schedule 17 B - Community Need See  Schedules Required for Each Type of CON to determine when this form is required. Public Need Summary: Briefly summarize on this schedule, why the project is needed. Use additional paper, as necessary. If the following items have been addressed in the project narrative, please cite the relevant section and pages. Identify the relevant service area (e.g., Minor Civil Division(s), Census Tract(s), street boundaries, Zip Code(s), Health Professional Shortage Area (HPSA) etc.)  FORMTEXT       Provide a quantitative and qualitative description of the population to be served. (Qualitative data may include median income, ethnicity, payor mix, etc.)  FORMTEXT       Document the current and projected demand for the proposed services. If the proposed services are covered by a DOH need methodology, demonstrate how the proposed service is consistent with it.  FORMTEXT       (a) Describe how this project responds to and reflects the needs of the residents in the community you propose to serve.  FORMTEXT       (b) Describe how this project is consistent with your facility s Community Service Implementation Plan (voluntary not-for-profit hospitals) or strategic plan (other providers).  FORMTEXT       (c) Will the proposed project serve all patients needing care, regardless of their ability to pay or the source of payment? If so, please provide such a statement.  FORMTEXT       Describe where and how the population to be served currently receives the proposed services.  FORMTEXT       ONLY For Applicants Seeking Permanent Life Diagnostic and Treatment Centers seeking approval for a Permanent Life MUST provide the following information: Instructions: In the space below, please provide detailed information on the most recent CON application that was approved for the limited life. CON number:  FORMTEXT       Date of approval:  FORMTEXT       Number of years of limited life approved for:  FORMTEXT       OpCert number and dates:  FORMTEXT       Please provide a table with information on projections by payor for year 1 and year 3 as reported on the approved CON. (Please identify the projections in terms of visits or procedures). Please provide a table with information on actual utilization by payor for each year since the implementation of the approved CON. Note: Please use the same category of payors for actual utilization as those used for projections in item v above. Also, use the same category (i.e., visits or procedures) for actual utilization as those used for projections in item v above. Did you achieve those projections reported in item 'v' above? If not, please give reasons for not meeting those projections. How do you plan to improve this shortfall?  FORMTEXT       Quality and Accreditation: Please cite relevant accreditations, certifications or awards attained by the applicant which build confidence in services of high quality. Examples include certification as a Federally Qualified Neighborhood Health Center.  FORMTEXT       Describe relevant programs or resources the applicant will bring to the new facility. Include existing programs that have proven track records at the applicant s other sites, if applicable, as well as programs the applicant plans for the future. Such programs include: Programs specially tailored to the health needs of the population of the service area. Grant funded programs. Scholarships or fellowships.  FORMTEXT       Describe the applicant s experience or track record serving similar populations:  FORMTEXT       Primary and Specialty Care Services Review Criteria: Expansion of Services When a CON application proposes conversion of a group or solo medical practice to Article 28 status, the applicant must provide a written analysis of the effect of the proposal on the following factors: The full time equivalent (FTE) number of primary care physicians and specialists, by specialty, engaged in the practice after the conversion compared with the number before conversion.  FORMTEXT       The (FTE) number of non-physician providers of primary care and specialty care, by specialty, such as Physician Assistants, Certified Nurse Practitioners, Physical Therapists, and Dental Assistants after the conversion compared with the number before conversion.  FORMTEXT       The number of primary care and specialty visits, by specialty, after the conversion compared with the number before conversion.  FORMTEXT       The array of services to underserved clients after the conversion compared with the number before conversion.  FORMTEXT       Target Population and Service Area: All applications involving primary care services must provide a written analysis that clearly demonstrates that the proposal meets at least one of the following criteria. For criteria that do not apply, enter "not applicable": The proposed clinic is in an underserved area as indicated by location in a Health Professional Shortage Area (HPSA) or Medically Underserved Area (MUA).  FORMTEXT       The population to be served exhibits poor health status, as measured by factors such as high levels of inpatient discharges for ambulatory care sensitive conditions (ACSC), incidences of diseases and conditions in excess of standards in Healthy People 2010 or other pertinent indicators.  FORMTEXT       The primary care services of the proposed clinic will be targeted to a group or population with special needs or conditions that make it difficult for them to obtain adequate primary care in clinics or physician practices serving the general population. Examples of such needs and conditions are: Developmental disabilities. HIV. Alcohol Substance Abuse. Health needs relating to aging. Mental Health needs. Homelessness Linguistic or cultural barriers in obtaining access to primary care.  FORMTEXT       Capacity of Existing Primary Care Providers The project narrative should describe existing primary care services in the proposed service area. The narrative should include the number and location of existing D&TCs, extension clinics and part-time clinics and a summary of primary care services available through private practices. The narrative should indicate whether travel time and transportation are factors in access to primary care. Examples of travel related issues include topography, seasonal weather conditions, and availability of public transportation. Applicants are not expected to describe the volume of services delivered by existing providers, since they will rarely have access to such data, but the project narrative should indicate that the applicant is reasonably familiar with the overall availability of primary care in the targeted area. In instances where the target area is likely to already have significant primary care resources, the CON proposal will be reviewed for the following need related factors: The ratio of primary care physicians to population in the proposed service area. HPSA uses a ratio of 1.0 FTE physicians to 3000 persons; Medicaid Managed Care uses a ratio of 1 to 1500. The number of primary care physicians in the proposed service area who are "active" in serving the Medicaid population. This is often measured as physicians who are reimbursed $5000 or more per year by Medicaid. The annual number of primary care visits per person by Medicaid eligible persons in the proposed service area. An average lower than 2.0 visits per person is often considered a problem. The percentage of the Medicaid population that is enrolled in Managed care will be taken into account where appropriate. The current volume of primary care visits to existing D&TC and Extension clinics. Not all of the above criteria need be evaluated for all applications. The number will vary depending on the type and location of services proposed and on how thoroughly the application addresses need in the project narrative and the related schedules.  FORMTEXT       Need Review for Specialty Clinics: Applications not involving primary care services must also provide a written analysis that clearly demonstrates that the need exists for the proposed services Is the proposed clinic in an underserved area as indicated by location in a Health Professional Shortage Area (HPSA) or Medically Underserved Area (MUA)?  FORMTEXT       Describe in very specific terms the patients who require the specialty services, including the number of patients and their specific health problems, and how the proposed facility will meet their needs better than existing providers.  FORMTEXT       In the case of Dental clinics, is the application supported by the local Health Department? Is the proposal supported by the Department of Health s Bureau of Dental Services? Is the applicant participating in current dental health initiatives? Has the applicant consulted with resources such as the New York State Oral Health Technical Assistance Center?  FORMTEXT       Impact of Proposed CON on Diagnostic & Treatment Center Operating Certificate The Sites Tab in NYSE-CON has replaced the Authorized Services Table of Schedule 17C. The Authorized Services Table in Schedule 17C is only to be used when submitting a Modification, in hardcopy, after approval or contingent approval. TABLE 17C-1 AUTHORIZED CERTIFIED SERVICES Instructions:For applications requesting changes to more than one location, complete a separate Table 17-C-1 for each location LOCATION:  FORMTEXT       (Enter street address of facility) FORMCHECKBOX  MOBILE CLINIC DESIGNATION (217) Check box only if extension clinic is mobile (A mobile clinic must be an extension clinic with a fixed main site) Existing AddRemoveProposed MEDICAL SERVICES PRIMARY CARE6 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX MEDICAL SERVICES OTHER MEDICAL SPECIALTIES FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX ABORTION FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX ADULT DAY HEALTH - AIDS FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX AMBULATORY SURGERY MULTI-SPECIALTY4 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  SINGLE SPECIALTY GASTROENTEROLOGY4 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  SINGLE SPECIALTY OPHTHALMOLOGY4 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  SINGLE SPECIALTY ORTHOPEDICS4 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  SINGLE SPECIALTY -- PAIN MANAGEMENT4 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  SINGLE SPECIALTY -- OTHER (SPECIFY) 4  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX BIRTHING SERVICE O/P FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX CERTIFIED MENTAL HEALTH O/P 1 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX CHEMICAL DEPENDENCE - REHAB 2 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX CHEMICAL DEPENDENCE - WITHDRAWAL O/P 2 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX CLINIC PART TIME SERVICES FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX CT SCANNER FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX DENTAL O/P FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX HOME HEMODIALYSIS TRAINING AND SUPPORT4 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX HOME PERITONEAL DIALYSIS TRAINING AND SUPPORT4 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX INTEGRATED SERVICES MENTAL HEALTH FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX INTEGRATED SERVICES SUBSTANCE USE DISORDER FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX LITHOTRIPSY O/P FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX MAGNETIC RESONANCE IMAGING (MRI) FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX METHADONE MAINTENANCE O/P FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX NURSING HOME HEMODIALYSIS7 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX RADIOLOGY THERAPEUTIC O/P5 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX RENAL DIALYSIS, CHRONIC [Complete the ESRD section 17C-1(a)&(b) below]4 $+EFQR\] = > N O P Z [ \   ǽΕ΍΂ttjhWUmHnHujhWUjhWU hW5 h(%hWh(% h{Y>h{Y> h{Y>5CJh{Y>hm5CJh{Y>hW5CJ hW5CJhW h 5CJ$ hW5CJ$ h5CJ$ hW5CJ( h5CJ(hWB*CJph-$FQR\]= > N O gd(%gd{Y> & F" t^ `tgdQa  & F">`>gdT$a$$a$         ( > @ h  P b d f h j ~ պvfjhCh B*Uphh>Ih'CJ^JaJ#jhCh B*UmHnHphujhCh B*UphhCh B*phjhCh B*Uph h>Ih'h{Y>CJ^JaJh'CJ^JaJhMh'CJ^JaJh'hWjhWUjhWUmHnHu(O       h  f d8$3$5$Ifgd{Y> d83$5$gd''xx$d%d&d'dNOPQ f h d8$3$5$Ifgd[ nkdt$$Ifl#$ t0644 lap yt[  d8$3$5$Ifgd[ nkdj$$Ifl#$ t0644 lap yt[    &(*,.02468:<PRTVXZŵťŕŅjhCh B*UphjhCh B*UphjhCh B*UphjhCh B*UphhCh B*ph h>Ih'h>Ih'CJ^JaJ#jhCh B*UmHnHphujhCh B*Uph4 d8$3$5$Ifgd[ nkd`$$Ifl#$ t0644 lap yt[  d8$3$5$Ifgd[ nkdV$$Ifl#$ t0644 lap yt[ 8d8$3$5$Ifgd[ nkdL$$Ifl#$ t0644 lap yt[ 8:bd8$3$5$Ifgd[ nkdB$$Ifl#$ t0644 lap yt[ Z\^`bdfz|~Ĵ̧}}}}}̧m}}}}}jh ^sB*Uph#jh ^sB*UmHnHphujh ^sB*Uphh ^sB*phjh ^sB*UphjhCh B*UphhCh B*ph h>Ih'h>Ih'CJ^JaJjhCh B*Uph#jhCh B*UmHnHphu*bdd8$3$5$Ifgd[ nkd8$$Ifl#$ t0644 lap yt[ d8$3$5$Ifgd[ nkd.$$Ifl#$ t0644 lap yt[ d8$3$5$Ifgd[ nkd$$$Ifl#$ t0644 lap yt[ 6Xvvhvh7 & F*d83$5$gd'd83$5$`gd' d83$5$gd'nkd $$Ifl#$ t0644 lap yt[  6V  02FHJLNPRTVXZܽ~~~~~ܽs~~~~~ܽj h'Ujh'UmHnHuj h'U hmLh'5B*OJQJph)jhmLh'5B*OJQJUph hmLh'CJOJQJ^JaJ *h>Ih'CJ^JaJh'CJ^JaJhMh'CJ^JaJh>Ih'CJ^JaJ)XZ$&bd@BD24^`* & F7 & F+d83$5$gd' d83$5$gd'7 & F*d83$5$gd'd83$5$`gd'$&:<PRTVXZ\^`bdٴٌsssssٴٌhsssssٴjl h'Ujh'UmHnHuj h'U hmLh'5B*OJQJphh'CJ^JaJhMh'CJ^JaJ hmLh'CJOJQJ^JaJ&jh'5B*UmHnHphu)jhmLh'5B*OJQJUph!j h'5B*Uph(.02468:<>@BD\b24V\^`*+5ɸڤɞ~yrrlh~d~~d~y~~~\~jhWUhYh^ hWCJ hW5CJ hW5hWhXhW5hXhY5CJhXhW5CJ hWCJ&jh'5B*UmHnHphu!j h'5B*Uph hmLh'5B*OJQJph)jhmLh'5B*OJQJUph hmLh'CJOJQJ^JaJ$567  JL`bdfhjlnprt.8 "np*,.02468:ڵڮڗj hWUhW5B*CJph hW5CJj< hWUhNAhWB*phhfj hWUhWjhWUmHnHujhWUjT hWU;*Jrt "<>hd3$5$]^hgd'h^h  & F h & F'xx$d%d&d'dNOPQ:<>(*,.02468:<  "yuhlxj hWUjh UmHnHujh Uh jh Uh'h 56B*CJph h'5CJh'h/05CJh'h'5CJjhWUmHnHuj$hWUjhWU hW5CJhW.:< "$&(*,.02468:'xx$d%d&d'dNOPQ & F*xx$d%d&d'dNOPQgd "$&(*,.02468:prt D }hWLjh'U hmLh'5B*OJQJph)jhmLh'5B*OJQJUphh'B*OJQJ^Jph!hmLh'B*OJQJ^Jph'hmLh'5B*CJ\^JaJph!hmLh'B*CJ^JaJphhmLh'5B*aJphhmLh'B*aJphhmLh'56B*aJphhmLh'6B*aJphhlx:rt ,!.!!!""##K$L$C%D%%8^8gd'7gd'7^gd' 7 & F)1$gd'm$w^wgd'^gd'  3$5$gd' !!!!! !"!$!&!(!*!,!.!!!!!!!!!!!!!!!!!""""" 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$Ifgd=kd{X$$Ifr^f!D%*ap2yt=f^g^u^v^w^x^y^^^^^^^^^^^^^^^^^^^^^^^^^^^^^___鼱qiiiih+qPJ^Jj]hwh=U^Jj]hwh=U^Jj\hwh=U^Jj'\hwhRU^Jhwh=PJ^JhE/ h=CJ^JaJjZhwh=U^Jj_Zhwh=U^Jhwh=^Jjhwh=U^J%^^^^^^^bYMMMM $$Ifa$gd= $Ifgd=kdK[$$Ifr^f!D%*ap2yt|z^^ __-_?_Q_bYMMMM $$Ifa$gd+q $Ifgd+qkd]$$Ifr^f!D%*ap2yt|z__ _ _______*_+_,_-_._<_=_>_?_@_N_O_P_Q_R_i_m_n_o_p_~______ҲҢҒ҅}qajahwh+qU^Jhwh+qH*PJ^Jh+qPJ^JhE/ h+qCJ^JaJj=`hwh+qU^Jj_hwh+qU^JjQ_hwh+qU^Jj^hwh|WU^Jhwh+q^Jjhwh+qU^Jhwh+qPJ^Jh+qh+qH*PJ^J#Q_R_o_____bYMMMM $$Ifa$gd+q $Ifgd+qkd`$$Ifr^f!D%*ap2yt|z_____________________________`ٹ٬~p~p~p~pfdQ%jhwh+q>*B*U^JphUh>Mh+qH*^Jh+qCJOJQJ^JaJ hcoh+qCJOJQJ^JaJh+qCJ^JaJh+qPJ^Jhwh+qPJ^JhE/ h+qCJ^JaJjbhwh+qU^Jj{bhwh+qU^Jhwh+q^Jjhwh+qU^Jjbhwh+qU^J__`(PxbYMMMM $$Ifa$gd+q $Ifgd+qkdgc$$Ifr^f!D%*ap2yt|z FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      TRAUMATIC BRAIN INJURY PROGRAM O/P FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  1 A separate licensure application must be filed with the NYS Office of Mental Health in addition to this CON. 2 A separate licensure application must be filed with the NYS Office of Alcoholism and Substance Abuse Services in addition to this CON. 4 Require additional approval by Medicare 5 RADIOLOGY  THERAPEUTIC includes Linear Accelerators. 6 PRIMARY CARE includes one or more of the following: Family Practice, Internal Medicine, Ob/Gyn or Pediatric 7 Must be certified for Home Hemodialysis Training & Support END STAGE RENAL DISEASE (ESRD) TABLE 17C-1(a) CAPACITYExisting AddRemoveProposed CHRONIC DIALYSIS FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       If application involves dialysis service with existing capacity, complete the following table: TABLE 17C-1(b) PROCEDURES Last 12 mos 2 years prior3 years priorCHRONIC DIALYSIS FORMTEXT       FORMTEXT       FORMTEXT       All Chronic Dialysis applicants must provide information requested on the following page in compliance with 10 NYCRR 670.6. END STAGE RENAL DISEASE Provide a five-year analysis of projected costs and revenues that demonstrates that the proposed dialysis services will be utilized sufficiently to be financially feasible.  FORMTEXT       Provide evidence that the proposed dialysis services will enhance access to dialysis by patients, including members of medically underserved groups which have traditionally experienced difficulties obtaining access to health care, such as; racial and ethnic minorities, women, disabled persons, and residents of remote rural areas.  FORMTEXT       Provide evidence that the hours of operation and admission policy of the facility will promote the availability of dialysis at times preferred by the patients, particularly to enable patients to continue employment.  FORMTEXT       Provide evidence that the facility is willing to and capable of safely serving patients.  FORMTEXT       Provide evidence that the proposed facility will not jeopardize the quality of care or the financial viability of existing dialysis facilities. This evidence should be derived from analysis of factors including, but not necessarily limited to current and projected referral and use patterns of both the proposed facility and existing facilities. A finding that the proposed facility will jeopardize the financial viability of one or more existing facilities will not of itself require a recommendation to of disapproval.  FORMTEXT       Table 17C-2 - Projected Utilization of Services: The number of projected "visits" should be listed in this table for each existing or proposed certified service. Visits should be estimated for the current, first and third year of the project. This table should contain visit estimates for services at this site alone, not for the applicant s other sites. Current Year Visits*First Year Visits*Third Year Visits*CERTIFIABLE SERVICESMEDICAL SERVICES  PRIMARY CARE FORMTEXT       FORMTEXT       FORMTEXT      MEDICAL SERVICES  SPECIALTIES FORMTEXT       FORMTEXT       FORMTEXT      ABORTION FORMTEXT       FORMTEXT       FORMTEXT      ADULT DAY HEALTH - AIDS FORMTEXT       FORMTEXT       FORMTEXT      AMBULATORY SURGERY  GASTROENTEROLOGY FORMTEXT       FORMTEXT       FORMTEXT      AMBULATORY SURGERY  OPHTHALMOLOGY FORMTEXT       FORMTEXT       FORMTEXT      AMBULATORY SURGERY  ORTHOPEDICS FORMTEXT       FORMTEXT       FORMTEXT      AMBULATORY SURGERY -- PAIN MANAGEMENT FORMTEXT       FORMTEXT       FORMTEXT      AMBULATORY SURGERY -- OTHER SPECIALTY FORMTEXT       FORMTEXT       FORMTEXT      AMBULATORY SURGERY -- MULTI-SPECIALTY FORMTEXT       FORMTEXT       FORMTEXT      BIRTHING SERVICE O/P FORMTEXT       FORMTEXT       FORMTEXT      CLINIC PART TIME SERVICES FORMTEXT       FORMTEXT       FORMTEXT      CLINIC SCHOOL BASED SERVICES FORMTEXT       FORMTEXT       FORMTEXT      CLINIC SCHOOL BASED DENTAL PROGRAM FORMTEXT       FORMTEXT       FORMTEXT      CT SCANNER FORMTEXT       FORMTEXT       FORMTEXT      DENTAL O/P FORMTEXT       FORMTEXT       FORMTEXT      HOME HEMODIALYSIS TRAINING AND SUPPORT FORMTEXT       FORMTEXT       FORMTEXT      HOME PERITONEAL DIALYSIS TRAINING AND SUPPORT FORMTEXT       FORMTEXT       FORMTEXT      INTERGRATED SERVICES  MENTAL HEALTH FORMTEXT       FORMTEXT       FORMTEXT      INTEGRATED SERVICES  SUBSTANCE USE DISORDER FORMTEXT       FORMTEXT       FORMTEXT      LITHOTRIPSY O/P FORMTEXT       FORMTEXT       FORMTEXT      MAGNETIC RESONANCE IMAGING (MRI) FORMTEXT       FORMTEXT       FORMTEXT      METHADONE MAINTENANCE FORMTEXT       FORMTEXT       FORMTEXT      NURSING HOME HEMODIALYSIS FORMTEXT       FORMTEXT       FORMTEXT      RADIOLOGY  THERAPEUTIC FORMTEXT       FORMTEXT       FORMTEXT      RENAL DIALYSIS, CHRONIC  FORMTEXT       FORMTEXT       FORMTEXT      TRAUMATIC BRAIN INJURY PROGRAM O/P FORMTEXT       FORMTEXT       FORMTEXT      UPGRADED DTC SERVICES FORMTEXT       FORMTEXT       FORMTEXT      OTHER SERVICES FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Total FORMTEXT       FORMTEXT       FORMTEXT       * The  Total reported MUST be the SAME as those on Table 13D-4     PAGE  DOH 155-D Schedule 17 cover (11/2019) DOH 155-D Schedule 17A cover (12/31/2003) New York State Department of Health Schedule 17A Certificate of Need Application PAGE 1 DOH 155-D Schedule 17A (11/2019) New York State Department of Health Schedule 17A Certificate of Need Application DOH 155-D Schedule 17A  PAGE 1 (12/31/2003) New York State Department of Health Schedule 17B Certificate of Need Application DOH 155-D Schedule 17B  PAGE 5 (11/2019) New York State Department of Health Schedule 17C Certificate of Need Application DOH 155-D Schedule 17C  PAGE 1 (12/31/2003) DOH 155-D Schedule 17C  PAGE 3 (11/2019) New York State Department of Health Schedule 14.3 Certificate of Need Application DOH 155-A Schedule 1  PAGE 1 (9/26/2002)  "$&(*:>@BDFHJLNPRfhjlnprtvxzȯȥȯȥyȯȥcȯ+jehwh+q>*B*U^Jph+j+ehwh+q>*B*U^Jph+jdhwh+q>*B*U^Jphhwh+q>*^J0jhwh+q>*B*U^JmHnHphu%jhwh+q>*B*U^Jph+jCdhwh+q>*B*U^Jphhwh+q>*B*^Jph&  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