Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 4 - Certificate of Need Regulations › Subchapter 1 - General › Section 310:4-1-13 - Description of application forms

Current through Vol. 41, No. 20, July 1, 2024
(a)
Standard Application.
The standard application for a Certificate
				of Need requires the following:
(1) The names
				and addresses of the facility and contact person;
(2) Disclosure of the applicant's identity
				and information sufficient for the Department to determine whether
the
				applicant has been convicted of a felony criminal offense related to the
				operation or management of a long-term care facility
[63:1-853(D)(2)(d)], including but not limited to:
(A) Sworn and notarized statements confirming
				the lack of any such conviction from the applicant and each person with
				controlling interest;
(B) Social
				security numbers for the applicant and each person with a controlling interest;
(C) Birth dates for the applicant
				and each person with a controlling interest;
(D) Copies of certificates of incorporation,
				bylaws, articles of organization, company operating agreements, certificates of
				limited partnership, or equivalent documents maintained pursuant to state or
				federal law, and any amendments of such documents. In lieu of submitting a
				document that is not a public record previously filed with a local, state or
				federal government agency, an applicant may submit a sworn and notarized
				statement that includes all of the following information:
(i) Name and date of the document;
(ii) Name and address of each person or
				entity that has current or proposed interests, responsibilities or
				participation in the ownership, operation or management of the facility or that
				otherwise makes or influences any decision relating to expenditures or
				operations affecting the facility, whether the person or entity is identified
				in the disclosed document by proper name or by function;
(iii) Description of the interest,
				responsibility, and nature of participation of each person and entity named
				pursuant to (a)(2)(D)(ii) of this Section; and
(iv) Location, address, and telephone number
				of the place of business in Oklahoma where the applicant will make the
				documents available for inspection by the Department, upon the Department's
				written request;
(3) Historical operating and financial
				information for the applicant and the facility;
(4) Residents council and family council
				minutes for the applicant's facilities;
(5) A detailed description of the project;
(6) Projections of personnel needs
				and identification of the medical director;
(7) Construction and building information;
(8) Justification of need for the
				project; and
(9) Data and
				projections on financial and economic feasibility, including but not limited to
				the following as applicable:
(A) For
				conventional, bank, seller-carried, third party, or bond financing, a statement
				of the proposed principal amount, interest rate and repayment terms, and that
				the applicant has access to the required funds, signed under oath by a
				representative of the lending institution, seller, third party, or authority;
(B) For equity financing:
(i) An attested balance sheet for the
				applicant that is dated within the past twelve (12) months that reflects cash
				or cash equivalents sufficient to fund the project; or
(ii) A certificate of deposit or other proof
				that funds are available and have not been pledged for another purpose.
(C) For financing or
				other funding from or guaranteed by a third party that is not duly authorized
				or chartered as a bank:
(i) An attested
				balance sheet, certificate of deposit or other attested proof that is dated
				within the past twelve (12) months for the third party, unless the third party
				is a licensed insurer or surplus lines insurer, the United States of America, a
				state of the United States of America, or an agency or instrumentality thereof;
				and
(ii) Copies of organizational
				documents and contracts necessary to substantiate the relationship between the
				applicant and the third party.