POSITRON EMISSION TOMOGRAPHY (PET) SCANNER SERVICES

GOVERNING BODY RESOLUTION FOR WITHDRAWAL OF DATA COMMITMENTS

Michigan Department of Health & Human Services

CERTIFICATE OF NEED

LewisCassBuilding

320 S. Walnut St.

Lansing, Michigan48913

Phone: (517) 241-3344 – Fax: (517) 241-2962

AUTHORITY:PA 368 of 1978, as amended
COMPLETION:Is voluntary, but is required to obtain a Certificate of Need. If not completed, a Certificate of Need will not be issued.
1. This notice is for the withdrawal of the following data commitments. (Check all that apply)
New Cancer Data Diagnostic Cardiac Catheterization Data Intractable Epilepsy Data
2. Legal Name of CON Applicant / 3. CON Application Number
4. Proposed PET Scanner Location (Complete Address)
5. Name of Entity Committing Data / 6. Date of Meeting

(As required by sections 13, 15, and/or 16 of the CON Review Standards for Positron Emission Tomography (PET) Scanner Services, effective November 21, 2011)

Whereas, the applicant identified in Item 2 has filed with the Michigan Department of Health & Human Services an application proposing the initiation of positron emission tomography (PET) scanner services at the location identified in Item 4.

Whereas, sections 13, 15, and 16 of the revised CON Review Standards for Positron Emission Tomography (PET) Scanner Services, effective November 21, 2011, allows the Department, Certificate of Need Section, to consider a withdrawal of diagnosis specific new cancer case data, diagnostic cardiac catheterization case data, and/or intractable epilepsy data, respectively, after the 120-day application review cycle following the date on which the Department review of the application commenced, or for five (5) years from the date of start of operations of the approved PET service for which the data are being committed, or the application is denied or expired, or the data is withdrawn in accordance with Administrative Rule 325.9204.

Whereas, the withdrawal must be submitted to the Department in the form of a governing body resolution that contains the certificate of need application number to which the data were originally committed, the legal applicant entity, the committing entity, the type of data, the date of the meeting in which the governing body authorized the withdrawal of the data, the governing body president’s signature, and the date of the signature; and

Therefore, be it resolved that the governing body of the entity noted in Item 5 above is withdrawing its commitment of data to the above-referenced certificate of need application that was submitted in accordance with the requirements of sections 13, 15, and/or 16, as applicable, of the CON Review Standards for Positron Emission Tomography (PET) Scanner Services, effective November 21, 2011.

CERTIFICATION

The foregoing resolution to withdraw commitment of data was adopted by the Governing Body of the entity noted in Item 5 above, in support of CON Application Number noted above, at its regular meeting held on the date shown above, at which a quorum was continuously present.

Name of Governing Body President / SignatureDate
Facility Name / MDHHS Facility Number
(if licensed facility)

CON-733-B Withdrawal (04-15) Page 1 of 1