The agency's request for a variance must include—

(a) The name, location, and type of the remote facility;

(b) The number of total patient admissions and the average daily patient census at the facility in the 6 months preceding the request;

(c) The number of Medicare and Medicaid patient admissions and the average daily Medicare and Medicaid patient census at the facility in the 6 months preceding the request;

(d) The name and location of each hospital, mental hospital, and ICF located within a 50-mile radius of the facility;

(e) The distance and average travel time between the remote facility and each facility listed in paragraph (e) of this section;

(f) Documentation by the facility of its attempts to obtain the services of available physicians or other professional personnel, or both;

(g) The names of all physicians on the active staff, and the names of all other professional personnel on the staff whose availability is relevant to the request;

(h) The practice locations of available physicians and the estimated number of available professional personnel whose availability is relevant to the request;

(i) Documentation by the facility of its inability to perform UR within the time requirements for which the variance is requested and its good faith efforts to comply with the UR plan requirements of subpart C or D of this part;

(j) An assurance by the facility that it will continue its good faith efforts to meet the UR plan requirements of subpart C or D of this part; and

(k) A statement of whether a planning or conditional PSRO exists in the area where the facility is located.

[43 FR 45266, Sept. 29, 1978, as amended at 61 FR 38399, July 24, 1996]