HFC Forms

If requesting a Word version of the following files, please email your request to hsda.staff@tn.gov .

Versions of the following forms dated prior to September 1, 2021 will not be accepted.

All documents must be received by Health Facilities Commission during normal business hours (8am to 4:30pm Central Time).

CON Applicant Self Check List (Optional)

Instructions for Completing Certificate of Need Application

Letter of Intent/Publication of Intent (Revised May 2022)

Certificate of Need Application (Revised December 2022)

Attachment-Bed Count

Attachment-Licensed County

Attachment-Medical Equipment

Attachment-Tennessee County Map

Letter of Intent/Publication of Intent-Relocation Exemption (Revised)

Relocation Exemption Request (Updated)

Temporary Exemption from Voiding CON

Economic Distressed Counties-CON Exemption

Affadavit for CON Application

Affadavit for Supplemental Responses

Affadavit for Lost Certificate of Need Certificate

Annual Progress Report

Final Project Report

Quality Measure Report

Link to Medical Equipment Forms

Intent to Alter Existing Bed Capacity (For Hospital and Nursing Home)

Copy Request Form

Public Records Request Form

Licensure and Regulation Forms

Hospital Bed Capacity Changes (Revised 2022)

Dialysis Service Request Form (2023)

Ventilator Unit Request Form (2022)

Home Health Accreditation Reporting Forms

Home Health Accreditation of CON Exempt Economic Distressed Counties

Home Health Agencies Exempted Due To Serving Pediatrics

Home Health Agencies Exempted Due to Serviing EEOICPA

If you need a Word version of the above forms, please email the request to hsda.staff@tn.gov .