Specialty:

Date:

Check the appropriate boxes:

Evidence of Documented Community Need: (Attach a dated copy Demand Tab)

QUANTITATIVE EVIDENCE:

There are not enough physicians in the community overall by population demand ratios of ____________(need) by ______________(year)

The population-to-physician ratio in the zip code of the new practice location in the

above specialty is below the ideal ratio in the GMENAC report or other accepted

benchmark as shown by a report prepared by a qualified and experienced consultant or

publicly available from other reputable sources, i.e., such report reflects a net need for

services at the new practice location and specialty (attach Demand Tool Tab, report or

relevant excerpts)

Waiting periods or travel times for patients seeking the above specialty services in the

hospital’s service area exceed statewide or national averages (attach supporting survey

Qualitative Tab Demand Tool)

The practice location is in an area designated as a Health Professional Shortage Area

(“HPSA”) as defined in 42 C.F.R. §§ 5.1 – 5.4 (attach proof of designation)

The practice location is in a Medically Underserved Area (“MUA”), designated by the

Secretary of HHS pursuant to 42 U.S.C. § 254b(b)(3) (attach proof of designation)

The population to be served is a Medically Underserved Population (“MUP”), designated

by the Secretary of HHS pursuant to 42 U.S.C. 254b(b)(3) (attach proof of designation)

The practice location has been designated a rural health clinic as defined in 42 U.S.C.

§ 1395x(aa)(2) or is an isolated rural area (attach copy of designation or other support)

The practice location has been designated a federally qualified health center (“FQHC”) as

defined in 42 U.S.C. § 1395x(aa)(2) or is an economically depressed inner-city area with a

median household income for a family of four of $___________ in the year ___________

compared to statewide median of $________ and a national median of $_________

(attach copy of designation and relevant census data or other proof of demographics)

Recruit will agree to serve a substantial number of patients (i.e., ___%) who: reside in a zip

code with a population-to-physician ratio below the ideal ratio; are part of an MUP;

or reside in a HPSA, MUA, or isolated rural area (agreement must define commitment)

There is a demonstrated reluctance of physicians to relocate to the hospital’s service area

(attach summary of unsuccessful recruitment efforts, including names of recruits, dates,

specialties and current practice location based on AMA or equivalent databases)

A reduction in the number of physicians in a specialty serving the community can be

reasonably expected as a result of anticipated retirement within the next three years

There are an insufficient number of physicians in the above specialty willing to accept

Medicare and/or Medicaid and indigent patients as determined by the hospital’s community

needs assessment and recruit will accept such patients on a nondiscriminatory basis (attach

Demand Tool Qualitative Tab assessment)

Recruit will staff a new facility or service in the community that has obtained a certificate

of need pursuant to state law which process included an examination of the need for the

service or facility in the community, i.e., a substantive or comparative review of need

Other factors related to cost, quality or access to care (e.g., disproportionately high number

of residents in specialty leave the state, donate time at indigent clinic or FQHC, accept

minimum level of charity care patients, essential to maintaining particular service at

hospital); requires approval of hospital legal counsel. Please explain here and attach

supporting documentation:

Range Documentation: Explain need number selected in range and why by specialty

a. Low_____________________________

b. Mean____________________________

c. High_____________________________

Explanation:

QUALITATIVE EVIDENCE

Demonstrate inadequate access (specific payor access and appointment wait times) Explanation:

Demonstrate loss of essential community program, not hospital-specific (i.e. Trauma). Explanation:

Demonstrate risk of loss of physicians next several years due to departures, those at “risk of retirement,” or reducing hours of practice. D. Demonstrate succession need:

Explanation:

Completed by: Third Party Assessment: Dated ________________

Completed by: In-House Assessment: Dated_________________

Completed by: ______________________________ Date: _________________________

This outline provides general information only and does not constitute legal or tax advice for any particular situation.