Ontario Certificate of Status Non Profit Corporation

Document Sample
Ontario Certificate of Status Non Profit Corporation Powered By Docstoc
					465 Status             465 App Number   1. HCP Number
2: Denied - Ineligible 17268-01-0001    17268

1: Approved         17268-01-0002       17268


1: Approved         17268-01-0003       17268


1: Approved         17268-01-0004       17268


1: Approved         17268-01-0005       17268


1: Approved         17268-01-0006       17268

1: Approved         17268-01-0007       17268

1: Approved         17268-01-0008       17268

1: Approved         17268-01-0009       17268


1: Approved         17268-01-0010       17268


1: Approved         17268-01-0011       17268


1: Approved         17268-01-0012       17268


1: Approved         17268-01-0013       17268


1: Approved         17268-01-0014       17268


1: Approved         17268-01-0015       17268


1: Approved         17268-01-0016       17268


1: Approved         17268-01-0017       17268
1: Approved         17268-01-0018       17268
1: Approved         17268-01-0019       17268
1: Approved         17268-01-0020       17268
1: Approved         17268-01-0021       17268
1: Approved   17268-01-0022   17268


1: Approved   17268-01-0023   17268


1: Approved   17268-01-0024   17268

1: Approved   17268-01-0025   17268

1: Approved   17268-01-0026   17268


1: Approved   17268-01-0027   17268

1: Approved   17268-01-0028   17268

1: Approved   17268-01-0029   17268

1: Approved   17268-01-0030   17268


1: Approved   17268-01-0031   17268


1: Approved   17268-01-0032   17268


1: Approved   17268-01-0033   17268


1: Approved   17268-01-0034   17268


1: Approved   17268-01-0035   17268

1: Approved   17268-01-0036   17268


1: Approved   17268-01-0037   17268


1: Approved   17268-01-0038   17268

1: Approved   17268-01-0039   17268


1: Approved   17268-01-0040   17268
1: Approved   17268-01-0041   17268
2. Consortium Name
Western New York Rural Area Health Education Center

Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center

Western New York Rural Area Health Education Center

Western New York Rural Area Health Education Center

Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center

Western New York Rural Area Health Education Center

Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center

Western New York Rural Area Health Education Center

Western New York Rural Area Health Education Center

Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center

Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center

Western New York Rural Area Health Education Center


Western New York Rural Area Health Education Center
Western New York Rural Area Health Education Center
3. HCP Name                                                               4. HCP FCC Reg Num
Western New York Rural Area Health Education Center                       0017512393

Brooks Memorial Hospital                                                  0017512393


Catholic Health System                                                    0017512393


Clifton Springs Hospital & Health Clinic                                  0017512393


Ira Davenport Memorial Hospital, Inc.                                     0017512393


Erie County Medical Center Corporation (ECMC)                             0017512393

Finger Lakes Migrant Health Care, Inc. (Sodus Clinic)                     0017512393

Finger Lakes Migrant Health Care, Inc. (Geneva Clinic)                    0017512393

Finger Lakes Migrant Health Care, Inc. (Port Byron Clinic)                0017512393


Geneva General Hospital                                                   0017512393


Jones Memorial Hospital                                                   0017512393


Kaleida Health                                                            0017512393


Lakeside Health System                                                    0017512393


Medina Memorial Health Care System                                        0017512393


Mount St. Mary's Hospital and Health Center                               0017512393


Niagara Falls Memorial Medical Center                                     0017512393


Nicholas H. Noyes Memorial Hospital                                       0017512393
Oak Orchard Community Health Center, Inc. (West Ave - Brockport Clinic)   0017512393
Oak Orchard Community Health Center, Inc. (Lyndonville Clinic)            0017512393
Oak Orchard Community Health Center, Inc. (West Ave - Ablion Clinic)      0017512393
Oak Orchard Community Health Center, Inc. (Albion Clinic)                 0017512393
Olean General Hospital                                        0017512393


Planned Parenthood of Western New York (Lockport Site)        0017512393


Planned Parenthood of Western New York (Niagara Falls Site)   0017512393

Rochester General (Via Health)                                0017512393

Schuyler Hospital                                             0017512393


St. James Mercy Health System                                 0017512393

St. Joseph's Hospital                                         0017512393

The Resource Center                                           0017512393

Thompson Health                                               0017512393


Tri-County Memorial Hospital                                  0017512393


Academic Medical Services                                     0017512393


UB Family Medicine, Inc.                                      0017512393


UB School of Medicine & Biomedical Sciences                   0017512393


University at Buffalo - Neurosurgery                          0017512393

United Memorial Medical Center                                0017512393


University Orthopaedic Services, Inc.                         0017512393


WCA Hospital                                                  0017512393

Westfield Memorial Hospital                                   0017512393


Wyoming County Community Health System                        0017512393
Lakeshore Health Care Center   0017512393
5a. Contact, First Name   5b. Contact, Middle Initial   5c. Contact, Last Name
Kenneth                   L                             Oakley, PhD, FACHE

Richard                                                 Ketchum


Joseph                    D                             McDonald


David                                                   Markant


James                     B                             Watson


Michael                   A                             Young

Mary Ann                                                Zelazny

Mary Ann                                                Zelazny

Mary Ann                                                Zelazny


James                     J                             Dooley


Robert                    J                             Bruckner


James                     R                             Kaskie


John                                                    Schrenker


James                     E                             Sinner


Judith                                                  Maness


Anthony                   F                             Zito


James                                                   Wissler
Dave                      W                             Fisher
Dave                      W                             Fisher
Dave                      W                             Fisher
Dave                      W                             Fisher
Timothy        J   Finan


Karen          J   Nelson


Karen          J   Nelson

David          B   Kamowski

V. Richard         Stelzer, Jr., FACHE


Mary           E   LaRowe

Sister Marie       Castagnaro, SSJ

Paul               Cesana

Deborah        K   Weymouth


Louis              Frascella


Alan           R   Saltzman, MD, MBA


Kathleen           Duttge


Judith         K   Miller


Mary Ann           Kedron

Mark           C   Schoell


Michael            Rogers


Betsy          T   Wright, FACHE

C. Angela          Bontempo, FACHE


Ronald         J   Krawiec
Louis   Frascella
6. Address Line 1          7. Address Line 2             8. County    9. City
20 Duncan Street           PO BOX 152                    Wyoming      Warsaw

529 Central Ave                                          Chautauqua   Dunkirk


Seton Professional Bldg.   2121 Main Street; Suite 300   Erie         Buffalo


2 Coulter Road                                           Ontario      Clifton Springs


7571 State Route 54                                      Steuben      Bath


462 Grider Street                                        Erie         Buffalo

6692 Middle Road           Suite 2100                    Wayne        Sodus

601B Washington Street                                   Ontario      Geneva

60 Main Street                                           Cayuga       Port Byron


196 North Street                                         Ontario      Geneva


191 North Main Street      PO BOX 72                     Allegany     Wellsville


100 High Street                                          Erie         Buffalo


156 West Ave                                             Monroe       Brockport


200 Ohio Street                                          Orleans      Medina


5300 Military Road                                       Niagara      Lewiston


621 Tenth Street                                         Niagara      Niagara Falls


111 Clara Barton Street                                  Livingston   Dansville
300 West Ave                                             Monroe       Brockport
77 South Main Street                                     Orleans      Lyndonville
301 West Ave                                             Orleans      Albion
245 South Main Street                                    Orleans      Albion
515 Main Street                                        Cattaraugus   Olean


38 Heritage Court                   PO BOX 498         Niagara       Lockport


732 Portage Road                    Haeberle Plaza     Niagara       Niagara Falls

333 Humboldt Street                                    Monroe        Rochester

220 Steuben Street                                     Schuyler      Montour Falls


411 Canisteo Street                                    Steuben       Hornell

555 East Market Street                                 Chemung       Elmira

800 East Second Street                                 Chautauqua    Jamestown

350 Parrish Street                                     Ontario       Canandaigua


100 Memorial Drive                                     Cattaraugus   Gowanda


462 Grider Street                                      Erie          Buffalo


462 Grider Street                   CC-162             Erie          Buffalo


155 Biomedical Education Building   3435 Main Street   Erie          Buffalo


3 Gates Circle                                         Erie          Buffalo

127 North Street                                       Genesee       Batavia


3435 Main Street                    Hayes Annex A      Erie          Buffalo


207 Foote Avenue                                       Chautauqua    Jamestown

189 East Main Street                                   Chautauqua    Westfield


400 North Main Street                                  Wyoming       Warsaw
845 Routes 5 & 20   Chautauqua   Irving
10. State   11. ZIP   12. Phone    13. Fax      14. Email
NY          14569     585-786-6275 585-786-6280 wnyrbhn@r-ahec.org

NY          14048     716-366-1111 716-363-7239 rketcham@brookshospital.org


NY          14214     716-862-2400 716-862-2468 pcapelli@chsbuffalo.org


NY          14432     315-462-0254 315-462-3492 david.markant@cshosp.com


NY          14810     607-776-8501 607-776-8817 ceojbw@idmh.org


NY          14215     716-898-3000 716-898-5650 myoung@ecmc.edu

NY          14451     315-483-1199 315-483-2451 maryz@flmhcp.org

NY          14456     315-781-8448 315-781-8444 maryz@flmhcp.org

NY          13160     315-776-9700 315-776-9701 maryz@flmhcp.org


NY          14456     315-787-4000 315-787-4029 jim.dooley@flhealth.org


NY          14895     585-593-1100 585-596-4005 brucknerb@jmhny.org


NY          14203     716-859-2732 716-859-3323 EBauerlein@kaleidahealth.org


NY          14420     585-395-6095 585-395-6007 jschrenker@lakesidehealth.org


NY          14103     585-798-2000 585-798-8444 jsinner@medinamemorial.org


NY          14092     716-298-2173 419-844-6157 Richard.Witowksi@msmh.org


NY          14302     716-278-4000 716-278-4054 anthony.zito@nfmmc.org


NY          14437     585-335-6001   585-335-5881   jwissler@noyes-hospital.org
NY          14420     585-637-3905   585-637-4990   dfisher@oochc.org
NY          14098     585-637-3905   585-637-4990   dfisher@oochc.org
NY          14411     585-589-5613   585-589-0872   dfisher@oochc.org
NY          14411     585-589-4519   585-637-4990   dfisher@oochc.org
NY   14760   716-373-2600 716-345-6394 tfinan@ogh.org


NY   14095   716-433-4427 716-831-1065 karen.nelson@ppwny.org


NY   14301   716-282-1223 716-831-1065 karen.nelson@ppwny.org

NY   14610   585-922-1651 585-922-1655 david.kamowski@viahealth.org

NY   14865   607-535-7121 607-535-9097 stelzerr@schuylerhospital.org


NY   14843   607-324-8113 607-324-8960 mlarowe@sjmh.org

NY   14901   607-633-6541 607-737-7837 mcastagnaro@stjosephs.org

NY   14701   716-661-1412                trcpaulcesana@alltel.net

NY   14424   585-396-6490 585-396-6477 deborah.weymouth@thompsonhealth.org


NY   14070   716-951-7034 716-532-8901 lfrascella@tlchealth.org


NY   14215   716-898-4328 716-898-3024 asaltzma@buffalo.edu


NY   14215   716-898-4744 716-898-4750 duttgeka@buffalo.edu


NY   14214   716-829-2975 716-829-2915 jkmiller@buffalo.edu


NY   14209   716-887-5200                Mkedron@buffns.com

NY   14020   585-344-5456 585-344-7434 mschoell@ummc.org


NY   14214   716-829-3670 716-829-3514 mrogers5@buffalo.edu


NY   14702   716-487-0141 716-664-8336 betsy.wright@wcahospital.org

NY   16544   716-326-4921 716-326-3802 abontem@svhs.org


NY   14569   585-786-8940 585-786-1222 rkrawiec@wcchs.net
NY   14081   716-951-7000 716-951-7046 lfrascella@tlchealth.org
15. Mailing Address                16a. Mailing Contact, First Name
2: No, go to Block 3 (26)

1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth

1: Yes, complete Block 2 (16-25)   Kenneth

1: Yes, complete Block 2 (16-25)   Kenneth

1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth
1: Yes, complete Block 2 (16-25)   Kenneth
1: Yes, complete Block 2 (16-25)   Kenneth
1: Yes, complete Block 2 (16-25)   Kenneth
1: Yes, complete Block 2 (16-25)   Kenneth
1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth

1: Yes, complete Block 2 (16-25)   Kenneth

1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth

1: Yes, complete Block 2 (16-25)   Kenneth

1: Yes, complete Block 2 (16-25)   Kenneth

1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth

1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth

1: Yes, complete Block 2 (16-25)   Kenneth


1: Yes, complete Block 2 (16-25)   Kenneth
1: Yes, complete Block 2 (16-25)   Kenneth
16b. Mailing Contact, Middle Initial   16c. Mailing Contact, Last Name


L                                      Oakley, PhD, FACHE


L                                      Oakley, PhD, FACHE


L                                      Oakley, PhD, FACHE


L                                      Oakley, PhD, FACHE


L                                      Oakley, PhD, FACHE

L                                      Oakley, PhD, FACHE

L                                      Oakley, PhD, FACHE

L                                      Oakley, PhD, FACHE


L                                      Oakley, PhD, FACHE


L                                      Oakley, PhD, FACHE


L                                      Oakley, PhD, FACHE


L                                      Oakley, PhD, FACHE


L                                      Oakley, PhD, FACHE


L                                      Oakley, PhD, FACHE


L                                      Oakley, PhD, FACHE


L                                      Oakley, PhD, FACHE
L                                      Oakley, PhD, FACHE
L                                      Oakley, PhD, FACHE
L                                      Oakley, PhD, FACHE
L                                      Oakley, PhD, FACHE
L   Oakley, PhD, FACHE


L   Oakley, PhD, FACHE


L   Oakley, PhD, FACHE

L   Oakley, PhD, FACHE

L   Oakley, PhD, FACHE


L   Oakley, PhD, FACHE

L   Oakley, PhD, FACHE

L   Oakley, PhD, FACHE

L   Oakley, PhD, FACHE


L   Oakley, PhD, FACHE


L   Oakley, PhD, FACHE


L   Oakley, PhD, FACHE


L   Oakley, PhD, FACHE


L   Oakley, PhD, FACHE

L   Oakley, PhD, FACHE


L   Oakley, PhD, FACHE


L   Oakley, PhD, FACHE

L   Oakley, PhD, FACHE


L   Oakley, PhD, FACHE
L   Oakley, PhD, FACHE
17. Mailing Organization                 18. Mailing Address Line 1


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street

WNY Rural Area Health Education Center   20 Duncan Street

WNY Rural Area Health Education Center   20 Duncan Street

WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street
WNY Rural Area Health Education Center   20 Duncan Street
WNY Rural Area Health Education Center   20 Duncan Street
WNY Rural Area Health Education Center   20 Duncan Street
WNY Rural Area Health Education Center   20 Duncan Street
WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street

WNY Rural Area Health Education Center   20 Duncan Street

WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street

WNY Rural Area Health Education Center   20 Duncan Street

WNY Rural Area Health Education Center   20 Duncan Street

WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street

WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street

WNY Rural Area Health Education Center   20 Duncan Street


WNY Rural Area Health Education Center   20 Duncan Street
WNY Rural Area Health Education Center   20 Duncan Street
19. Mailing Address Line 2   20. Mailing City   21. HCP Mailing Address State


PO BOX 152                   Warsaw             NY


PO BOX 152                   Warsaw             NY


PO BOX 152                   Warsaw             NY


PO BOX 152                   Warsaw             NY


PO BOX 152                   Warsaw             NY

PO BOX 152                   Warsaw             NY

PO BOX 152                   Warsaw             NY

PO BOX 152                   Warsaw             NY


PO BOX 152                   Warsaw             NY


PO BOX 152                   Warsaw             NY


PO BOX 152                   Warsaw             NY


PO BOX 152                   Warsaw             NY


PO BOX 152                   Warsaw             NY


PO BOX 152                   Warsaw             NY


PO BOX 152                   Warsaw             NY


PO BOX 152                   Warsaw             NY
PO BOX 152                   Warsaw             NY
PO BOX 152                   Warsaw             NY
PO BOX 152                   Warsaw             NY
PO BOX 152                   Warsaw             NY
PO BOX 152   Warsaw   NY


PO BOX 152   Warsaw   NY


PO BOX 152   Warsaw   NY

PO BOX 152   Warsaw   NY

PO BOX 152   Warsaw   NY


PO BOX 152   Warsaw   NY

PO BOX 152   Warsaw   NY

PO BOX 152   Warsaw   NY

PO BOX 152   Warsaw   NY


PO BOX 152   Warsaw   NY


PO BOX 152   Warsaw   NY


PO BOX 152   Warsaw   NY


PO BOX 152   Warsaw   NY


PO BOX 152   Warsaw   NY

PO BOX 152   Warsaw   NY


PO BOX 152   Warsaw   NY


PO BOX 152   Warsaw   NY

PO BOX 152   Warsaw   NY


PO BOX 152   Warsaw   NY
PO BOX 152   Warsaw   NY
22. Mailing ZIP   23. Mailing Phone   24. Mailing Fax   25. Mailing Email


14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org


14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org


14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org


14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org


14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org

14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org

14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org

14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org


14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org


14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org


14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org


14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org


14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org


14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org


14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org


14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org
14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org
14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org
14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org
14569             585-786-6275        585-786-6280      wnyrbhn@r-ahec.org
14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org


14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org


14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org

14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org

14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org


14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org

14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org

14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org

14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org


14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org


14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org


14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org


14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org


14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org

14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org


14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org


14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org

14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org


14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org
14569   585-786-6275   585-786-6280   wnyrbhn@r-ahec.org
26. Funding Year                     27a. Eligible Entity?
3: Year 2009 (7/1/2009: 6/30/2010)   No

3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes

3: Year 2009 (7/1/2009: 6/30/2010)   Yes

3: Year 2009 (7/1/2009: 6/30/2010)   Yes

3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes
3: Year 2009 (7/1/2009: 6/30/2010)   Yes
3: Year 2009 (7/1/2009: 6/30/2010)   Yes
3: Year 2009 (7/1/2009: 6/30/2010)   Yes
3: Year 2009 (7/1/2009: 6/30/2010)   Yes
3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes

3: Year 2009 (7/1/2009: 6/30/2010)   Yes

3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes

3: Year 2009 (7/1/2009: 6/30/2010)   Yes

3: Year 2009 (7/1/2009: 6/30/2010)   Yes

3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes

3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes

3: Year 2009 (7/1/2009: 6/30/2010)   Yes


3: Year 2009 (7/1/2009: 6/30/2010)   Yes
3: Year 2009 (7/1/2009: 6/30/2010)   Yes
27b. Eligible Entity Type
11: Other (ineligible) entity

5: Not-for-profit hospital


5: Not-for-profit hospital


5: Not-for-profit hospital


5: Not-for-profit hospital


5: Not-for-profit hospital

2: Community health center or health center providing health to migrants

2: Community health center or health center providing health to migrants

2: Community health center or health center providing health to migrants


5: Not-for-profit hospital


5: Not-for-profit hospital


5: Not-for-profit hospital


5: Not-for-profit hospital


5: Not-for-profit hospital


5: Not-for-profit hospital


5: Not-for-profit hospital


5: Not-for-profit hospital
2: Community health center or health center providing health to migrants
2: Community health center or health center providing health to migrants
2: Community health center or health center providing health to migrants
2: Community health center or health center providing health to migrants
5: Not-for-profit hospital


10: Urban Health Clinic


10: Urban Health Clinic

5: Not-for-profit hospital

5: Not-for-profit hospital


5: Not-for-profit hospital

5: Not-for-profit hospital

6: Rural health clinic

5: Not-for-profit hospital


5: Not-for-profit hospital


1: Post-secondary educational institution offering health care instruction, teaching hospital or medical school


1: Post-secondary educational institution offering health care instruction, teaching hospital or medical school


1: Post-secondary educational institution offering health care instruction, teaching hospital or medical school


1: Post-secondary educational institution offering health care instruction, teaching hospital or medical school

5: Not-for-profit hospital


1: Post-secondary educational institution offering health care instruction, teaching hospital or medical school


5: Not-for-profit hospital

5: Not-for-profit hospital


5: Not-for-profit hospital
6: Rural health clinic
27c. Explanation of Eligibility
Ineligible Entity
In accordance with NYS law, Dept. of Health issued Operating Certificate # 0601000H, and is a non-
profit hospital.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; was issued a NYS DOH Operating Certificate 1401013H, 1404000H, and 1401008H
and is a non-profit hospital.
Hospital licensed under New York State Department of Health, in accordance with the New York
State Law, Article 28; NYSDOH Operating Certificate # 342100H, and is a not-for-profit and teaching
hospital

Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate # 5022000H and is a not-for-profit hospital.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate # 1401005H and is a not-for-profit and teaching
hospital.
Eligibility for this entity is based upon the fact that they were certified as a Federally Qualified Health
Center as well as providing healthcare to migrants.
Eligibility for this entity is based upon the fact that they were certified as a Federally Qualified Health
Center as well as providing healthcare to migrants.
Eligibility for this entity is based upon the fact that they were certified as a Federally Qualified Health
Center as well as providing healthcare to migrants.

Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate #3402000H and is a not-for-profit hospital.

Hospital licenssed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate #0228000H and is a not-for-profit hospital.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate # 1401014H and is a not-for-profit and teaching
hospital.

Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate #2728001H and is a not-for-profit hospital.

Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate # 3622000H and is a not-for-profit hospital.

Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate #3121001H and is a not-for-profit hospital.

Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate #3102000H and is a not-for-profit hospital.

Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate # 2527000H and is a not-for-profit hospital.
Eligibility is based on the fact that they are deemed to be a Federally Qualified Health Center.
Eligibility is based on the fact that they are deemed to be a Federally Qualified Health Center.
Eligibility is based on the fact that they are deemed to be a Federally Qualified Health Center.
Eligibility is based on the fact that they are deemed to be a Federally Qualified Health Center.
Hospital licensed under New York State Department of Health, in accordance with New York State
Law, Article 28; NYSDOH Operating Certificate #0401001H and is a not-for-profit hospital.

Eligibility is based upon the fact that they are a non-profit health care agency. With an operating
certificate issued by the New York State Department of Health # 1401235R, facility id # 2772

Eligibility is based upon the fact that they are a non-profit health care agency. With an operating
certificate issued by the New York State Department of Health # 1401235R, facility id # 576
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 2701003H.
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 48237000C

Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 5002001H and is a not-for-profit hospital.
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 1455000H
Eligibility is based upon the fact that they are a non-profit health care agency, with an operating
certificate issued by the NYS Department of Health # 060221R
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 3429000H

Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 0427000H and is a not-for-profit hospital.
Teaching facility for medical Residency training programs leading to M.D. degree in Internal
Medicine offered by UB School of Medicine & Biomedical Sciences. Clinical faculty at the facility also
contribute to academic Ph.D. programs.
Teaching facility for medical Residency training programs leading to M.D. degree in Family Medicine
offered by UB School of Medicine & Biomedical Sciences. Clinical faculty at the facility also
contribute to academic Ph.D. programs.
Nationally-accredited School of Medicine and Biomedical Scineces with formal medical and nursing
educationalprograms leading to M.D., BSN and MSN degrees. Complete list of clinical educational
programs found at the link: http://www.smbs.buffalo.edu/education.php
Teaching facility for medical Residency training programs leading to M.D. degree in Neurosurgery
offered by UB School of Medicine & Biomedical Sciences. Clinical faculty at the facility also
contribute to academic Ph.D. programs.
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 1801000H
Teaching facility for medical Residency training programs leading to M.D. degree in Orthopedics
offered by UB School of Medicine & Biomedical Sciences. Clinical faculty at the facility also
contribute to academic Ph.D. programs.

Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 0602001H and is a not-for-profit hospital.
Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 0632000H

Hospital licensed under New York State Department of Health, in acccordance with New York State
Law, Article 28: NYSDOH Operating Certificate # 6027000H and is a not-for-profit hospital.
Health Clinic licensed under New York State Department of Health, in acccordance with New York
State Law, Article 28: NYSDOH Operating Certificate # 0427000H and is a not-for-profit rural health
clinic.
28. Description of Consortium, Dedicated ER Dept or Part-Time
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
29: Description of Telecom/Internet Services


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.

Provisioned with a minimum 20 mpbs scaleable IP connectivity.

Provisioned with a minimum 20 mpbs scaleable IP connectivity.

Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.

Provisioned with a minimum 20 mpbs scaleable IP connectivity.

Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.

Provisioned with a minimum 20 mpbs scaleable IP connectivity.

Provisioned with a minimum 20 mpbs scaleable IP connectivity.

Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.

Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.

Provisioned with a minimum 20 mpbs scaleable IP connectivity.


Provisioned with a minimum 20 mpbs scaleable IP connectivity.
Provisioned with a minimum 20 mpbs scaleable IP connectivity.
31. Certify authorized to submit request for HCP?
                          TRUE

                         TRUE


                         TRUE


                         TRUE


                         TRUE


                         TRUE

                         TRUE

                         TRUE

                         TRUE


                         TRUE


                         TRUE


                         TRUE


                         TRUE


                         TRUE


                         TRUE


                         TRUE


                         TRUE
                         TRUE
                         TRUE
                         TRUE
                         TRUE
TRUE


TRUE


TRUE

TRUE

TRUE


TRUE

TRUE

TRUE

TRUE


TRUE


TRUE


TRUE


TRUE


TRUE

TRUE


TRUE


TRUE

TRUE


TRUE
TRUE
32. Certify HCP followed state or local procurement rules?
                              TRUE

                              TRUE


                              TRUE


                              TRUE


                              TRUE


                              TRUE

                              TRUE

                              TRUE

                              TRUE


                              TRUE


                              TRUE


                              TRUE


                              TRUE


                              TRUE


                              TRUE


                              TRUE


                              TRUE
                              TRUE
                              TRUE
                              TRUE
                              TRUE
TRUE


TRUE


TRUE

TRUE

TRUE


TRUE

TRUE

TRUE

TRUE


TRUE


TRUE


TRUE


TRUE


TRUE

TRUE


TRUE


TRUE

TRUE


TRUE
TRUE
33. Certify will utilize telecom services for health care?
                                TRUE

                              TRUE


                              TRUE


                              TRUE


                              TRUE


                              TRUE

                              TRUE

                              TRUE

                              TRUE


                              TRUE


                              TRUE


                              TRUE


                              TRUE


                              TRUE


                              TRUE


                              TRUE


                              TRUE
                              TRUE
                              TRUE
                              TRUE
                              TRUE
TRUE


TRUE


TRUE

TRUE

TRUE


TRUE

TRUE

TRUE

TRUE


TRUE


TRUE


TRUE


TRUE


TRUE

TRUE


TRUE


TRUE

TRUE


TRUE
TRUE
34. Certify that HCP is nonprofit or public entity?
                          TRUE

                         TRUE


                         TRUE


                         TRUE


                         TRUE


                         TRUE

                         TRUE

                         TRUE

                         TRUE


                         TRUE


                         TRUE


                         TRUE


                         TRUE


                         TRUE


                         TRUE


                         TRUE


                         TRUE
                         TRUE
                         TRUE
                         TRUE
                         TRUE
TRUE


TRUE


TRUE

TRUE

TRUE


TRUE

TRUE

TRUE

TRUE


TRUE


TRUE


TRUE


TRUE


TRUE

TRUE


TRUE


TRUE

TRUE


TRUE
TRUE
35. Certify that HCP is located in a rural area?
                         TRUE

                        TRUE


                        TRUE


                        TRUE


                        TRUE


                        TRUE

                        TRUE

                        TRUE

                        TRUE


                        TRUE


                        TRUE


                        TRUE


                        TRUE


                        TRUE


                        TRUE


                        TRUE


                        TRUE
                        TRUE
                        TRUE
                        TRUE
                        TRUE
TRUE


TRUE


TRUE

TRUE

TRUE


TRUE

TRUE

TRUE

TRUE


TRUE


TRUE


TRUE


TRUE


TRUE

TRUE


TRUE


TRUE

TRUE


TRUE
TRUE
36. Certify that HCP satisfies all requirements?   38. Date
                        TRUE                          6/24/2009

                        TRUE                         6/24/2009


                        TRUE                         6/24/2009


                        TRUE                         6/24/2009


                        TRUE                         6/24/2009


                        TRUE                         6/24/2009

                        TRUE                         6/24/2009

                        TRUE                         6/24/2009

                        TRUE                         6/24/2009


                        TRUE                         6/24/2009


                        TRUE                         6/24/2009


                        TRUE                         6/24/2009


                        TRUE                         6/24/2009


                        TRUE                         6/24/2009


                        TRUE                         6/24/2009


                        TRUE                         6/24/2009


                        TRUE                         6/24/2009
                        TRUE                         6/24/2009
                        TRUE                         6/24/2009
                        TRUE                         6/24/2009
                        TRUE                         6/24/2009
TRUE   6/24/2009


TRUE   6/24/2009


TRUE   6/24/2009

TRUE   6/24/2009

TRUE   6/24/2009


TRUE   6/24/2009

TRUE   6/24/2009

TRUE   6/24/2009

TRUE   6/24/2009


TRUE   6/24/2009


TRUE   6/24/2009


TRUE   6/24/2009


TRUE   6/24/2009


TRUE   6/24/2009

TRUE   6/24/2009


TRUE   6/24/2009


TRUE   6/24/2009

TRUE   6/24/2009


TRUE   6/24/2009
TRUE   6/24/2009
39a. Authorized Person, First Name   39b. Authorized Person, Middle Initial
Kenneth                              L

Kenneth                              L


Kenneth                              L


Kenneth                              L


Kenneth                              L


Kenneth                              L

Kenneth                              L

Kenneth                              L

Kenneth                              L


Kenneth                              L


Kenneth                              L


Kenneth                              L


Kenneth                              L


Kenneth                              L


Kenneth                              L


Kenneth                              L


Kenneth                              L
Kenneth                              L
Kenneth                              L
Kenneth                              L
Kenneth                              L
Kenneth   L


Kenneth   L


Kenneth   L

Kenneth   L

Kenneth   L


Kenneth   L

Kenneth   L

Kenneth   L

Kenneth   L


Kenneth   L


Kenneth   L


Kenneth   L


Kenneth   L


Kenneth   L

Kenneth   L


Kenneth   L


Kenneth   L

Kenneth   L


Kenneth   L
Kenneth   L
39c. Authorized Person, Last Name   40. Title or Position
Oakley, PhD, FACHE                  CEO

Oakley, PhD, FACHE                  CEO


Oakley, PhD, FACHE                  CEO


Oakley, PhD, FACHE                  CEO


Oakley, PhD, FACHE                  CEO


Oakley, PhD, FACHE                  CEO

Oakley, PhD, FACHE                  CEO

Oakley, PhD, FACHE                  CEO

Oakley, PhD, FACHE                  CEO


Oakley, PhD, FACHE                  CEO


Oakley, PhD, FACHE                  CEO


Oakley, PhD, FACHE                  CEO


Oakley, PhD, FACHE                  CEO


Oakley, PhD, FACHE                  CEO


Oakley, PhD, FACHE                  CEO


Oakley, PhD, FACHE                  CEO


Oakley, PhD, FACHE                  CEO
Oakley, PhD, FACHE                  CEO
Oakley, PhD, FACHE                  CEO
Oakley, PhD, FACHE                  CEO
Oakley, PhD, FACHE                  CEO
Oakley, PhD, FACHE   CEO


Oakley, PhD, FACHE   CEO


Oakley, PhD, FACHE   CEO

Oakley, PhD, FACHE   CEO

Oakley, PhD, FACHE   CEO


Oakley, PhD, FACHE   CEO

Oakley, PhD, FACHE   CEO

Oakley, PhD, FACHE   CEO

Oakley, PhD, FACHE   CEO


Oakley, PhD, FACHE   CEO


Oakley, PhD, FACHE   CEO


Oakley, PhD, FACHE   CEO


Oakley, PhD, FACHE   CEO


Oakley, PhD, FACHE   CEO

Oakley, PhD, FACHE   CEO


Oakley, PhD, FACHE   CEO


Oakley, PhD, FACHE   CEO

Oakley, PhD, FACHE   CEO


Oakley, PhD, FACHE   CEO
Oakley, PhD, FACHE   CEO
41. Employer                                          42. Employer's FCC RN
Western New York Rural Area Health Education Center   0017512393

Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393

Western New York Rural Area Health Education Center   0017512393

Western New York Rural Area Health Education Center   0017512393

Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393
Western New York Rural Area Health Education Center   0017512393
Western New York Rural Area Health Education Center   0017512393
Western New York Rural Area Health Education Center   0017512393
Western New York Rural Area Health Education Center   0017512393
Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393

Western New York Rural Area Health Education Center   0017512393

Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393

Western New York Rural Area Health Education Center   0017512393

Western New York Rural Area Health Education Center   0017512393

Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393

Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393

Western New York Rural Area Health Education Center   0017512393


Western New York Rural Area Health Education Center   0017512393
Western New York Rural Area Health Education Center   0017512393

				
DOCUMENT INFO
Description: Ontario Certificate of Status Non- Profit Corporation document sample