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 Services and Development Agency 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 (Updated)

Attachment-Bed Count

Attachment-Licensed County

Attachment-Medical Equipment

Attachment-Tennessee County Map

Letter of Intent/Publication of Intent-Relocation Exemption

Relocation Exemption Request

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