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Exhibit 4 - Determination of Need Form

AMERICAN SAMOA

HEALTH PLANNING AND DEVELOPMENT AGENCY

L.B.J. TROPICAL MEDICAL CENTER

FAGA'ALU

 

DETERMINATION OF NEED FORM 100

A. This form is being submitted for

________ Application for determination of need

________ Notice of Intent for Health Facility

or services Project

B. Name of Facility or Organization

C. Project Contact:

Name ____________________________________________________________________Phone____________________________

Address____________________________________________________________________________________________________

D. Type of Project

 

__

_______ Renovation of Facility

_______ Equipment Only

E. Type of Facility

 

_______ Skilled Nursing

_______ Intermediate Care

F. Estimated Cost _________

 

(amounts)

(check all applicable)

 

 

_______ New Facility

_______ Hospital

G. Source of Funds

_____ Expansion of Facility

 

 

_______ Home Health Agency Federal _______________

_______ Addition of Beds _______ Kidney Disease Treatment Center GAS _________________

_______ Deletion of Beds _______ HMO

_______ Change in Bed _______ Ambulatory Health

Classification Care Facility

_______ Addition of Service _______ Other, specify H. Expected Date of

_______ Deletion of Service ____________________________________ Obligation of Funds

____________________________________ ____________________

 

I. Number of beds (if any) to be affected by the project:

____________ added, ________removed _______________ changed from ________ to ________

type type

J. Description of change in services offered :

K. Estimated Project Completion Date : ___________________________________________________

MonthYear

L. Summary Description of the Project and the Need it is Intended to Fill (attach separate sheet if needed)

M. Type of Review Request (see Procedure Manual, Determination of Need Rules)

_________ Standard

_________ Emergency (Explain on an attachment your justification for an emergency review.)

N. Assurance:

To the best of my knowledge the above description of the proposed project and the accompanying supportive information is an accurate representation of the true nature and scope of the project.

_______________________________ _____________________

SIGNATURE DATE