HFC Forms
NOTE: All forms are in PDF format unless otherwise annotated. If you need 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.
CON Applicant Self Check List (Optional)
Instructions for Completing Certificate of Need Application
Letter of Intent/Publication of Intent
Certificate of Need Application (Revised December 2022)
Attachment-Tennessee County Map
Letter of Intent/Publication of Intent-Relocation Exemption (Revised)
Relocation Exemption Request (Updated)
Temporary Exemption from Voiding CON
Economic Distressed Counties-CON Exemption
All documents must be received by Health Facilities Commission during normal business hours (8am to 4:30pm Central Time).
Intent to Alter Existing Bed Capacity (For Hospital and Nursing Home)
Advanced Care Directive Forms (link to Health Care Decision Making)
Physician Orders for Scope of Treatment (POST) Form (link to Health Care Decision Making)
RHA/ACLF Administrator Application Forms
Hospital Bed Capacity Changes (For Hospitals-Revised 2022)
Dialysis Service Request Form (2023)
Ventilator Unit Request Form (2023)
Initial Notification of Home Health Accreditation for CON Exemption
Annual Progress Report of Home Health Accreditation for CON Exemption
Final Report - Home Health Agencies Exempted Due To Serving Pediatrics
Final Report - Home Health Agencies Exempted Due to Serviing EEOICPA
Home Health Accreditation of CON Exempt Economic Distressed Counties
As of July 1, 2023, the Distressed Counties are Lake and Perry Counties.
If you need a Word version of the above forms, please email the request to hsda.staff@tn.gov .