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
