Hospital Conversion Packet


The forms and instructions in this packet are designed to assist providers in notifying Health Standards of the hospital’s intent to convert from one type of hospital to another type of hospital.

·        Licensing Forms

o   Cover Letter – Hospital Conversion Packet

o   License Application

o   Checklist for Hospital Conversion Packet

o   Worksheet for Hospital Rooms & Beds (HSS-HO-016a &/or HSS-HO-016b)

o   Disclosure of Ownership

o   Attestation for Hospitals

o   Perspective Owner Intention Regarding Medicare Certification Statement

o   Notification of Co-Located Status

o   Expression of Fiscal Year End Date Form

o   Plan Review Attestation Form

·        Related Items

o   Payment Transmittal Form (See the Hospital License Application which includes this form)

o   Hospital Approval by Other Agencies

o   Hospital Accrediting Organizations

o   Hospital Licensing Standards

o   Hospital Federal Regulations

o   Office of Civil Rights