Applications & Forms

Persons are encouraged to contact CON staff early in the project planning process.

All forms are interactive pdf file PDF forms, which can be typed into, and where applicable, check boxes may be checked and numerical fields are self-calculating. Once completed, forms need to be printed, signed (where applicable), included with other applications/forms and e-mailed or mailed to the Certificate of Need Program Office. If problems are encountered, contact CON staff.

Pre-Application Forms
      MO 580-1860 Letter of Intent
      For a new LTC bed proposal needing a CON, the average occupancy of all licensed and
      available beds in the radius is required.  Also, if the bed need standard is met, the bed need
      calculation and supporting documentation is required.  Or if special exceptions apply, an
      explanation is required.  Contact CONP for instructions at least one month in advance of the
      LOI filing if new to the process.

      For a non-applicability proposal to establish a LTC facility, add LTC beds under the 10/10% rule,
      replace LTC beds, or renovate/modernize a LTC facility, contact the DHSS Licensure and
      Engineering units for regulations prior to filing the Letter of Intent.

      MO 580-2375 Proposed Expenditures

Applicant Completeness Checklists
      MO 580-2501 New Hospital Application
      MO 580-2502 New or Additional Long Term Care Bed Application
      MO 580-2503 New or Additional Equipment Application
      MO 580-2504 Expedited LTC Bed Replacement/Expansion Application
      MO 580-2505 Expedited LTC Renovation/Modernization Application
      MO 580-2506 Equipment Replacement Application

Application Forms
      MO 580-1861 Applicant Identification and Certification
      MO 580-1869 Representative Registration
      MO 580-1863 Proposed Project Budget
      MO 580-2352 Purchase Agreement
      MO 580-1865 Service-Specific Revenues and Expenses

Other Forms
      Missouri Population Data & Maps Order Form
      MO 580-1870 Contact Person Correction
      MO 580-1871 Periodic Progress Report
      Request for Extension