N.H. Code Admin. R. He-C 6339.04 – Application for Enrollment and Certification for Payment Standards for Community-Based In-Home Service

(a) Applicants who seek initial certification for payment standards for community-based in home service shall contact a DCYF district office supervisor or designee and request to be referred for certification.
(b) Each applicant to be a provider of child health support services shall complete, sign, and submit, a Form 2603 “Application for Certification and Enrollment of Child Health Support Services Providers” (October 2016).
(c) Each applicant shall complete, sign, and submit a “Statement of Affirmation” as part of Form 2603 “Application for Certification and Enrollment of Child Health Support Service Providers” (October 2016), that certifies the following:
“I affirm that all the information contained in this application is true, correct, and complete to the best of my knowledge and belief. I acknowledge that the provision of false information in the review document is a basis for denial of the continuation of certification. I understand that DCYF has the right to review the information contained in this review document;
I affirm that I will notify DCYF in writing within 10 days of any change in the information contained in this review of continued certification;
By my signature below, I affirm that I have read and agree to adhere to administrative rule He-C 6339, “Certification for Payment Standards for In Home Community Based Service Providers.”
(d) Part C of Form 2603 “Application for Certification and Enrollment of Child Health Support Service Providers” (October 2016) shall be completed, signed, and dated by each direct service staff and include the following:
“I declare that all the information contained above is true, correct and complete to the best of my knowledge and belief. I acknowledge that the provision of false information in the application is a basis for denial of the application.”
(e) Each submitted and signed Part C of Form 2603 “Application for Certification and Enrollment of Child Health Support Service Providers” (October 2016) shall have the following attestation signed and dated by the executive director or designee:
“I certify that a criminal record check for this individual is completed and on file at the agency.”
(f) The applicant shall provide the following information with or in addition to Form 2603 “Application for Certification and Enrollment of Child Health Support Service Providers” (October 2016):
1. (1) A completed, signed, and dated “State of New Hampshire Alternative W-9. (October 2016);”
2. (2) A current list of the board of directors including the following for each member of the board:
  1. a. The full name;
  2. b. The office held;
  3. c. The professional affiliation; and
  4. d. The address, telephone, and email address;
3. (3) A copy of the organizational structure of the program;
4. (4) Prescribing practitioner’s license;
5. (5) A copy of the professional and general liability insurance certificate(s) for the program;
6. (6) A copy of the program brochure; and
7. (7) A copy of a current resume or curriculum vitae of the program consultant.
(g) Each applicant for home-based therapeutic services shall complete and submit a signed and dated Form 2604 “Application for Certification and Enrollment of Home-based Therapeutic Service Providers” (October 2016).
(h) A Part C of Form 2604 “Application for Certification and Enrollment of Home-based Therapeutic Service Providers” (October 2016) shall be signed and dated by each direct service staff, and include the following:
“I declare that all the information contained above is true, correct, and complete to the best of my knowledge and belief. I acknowledge that the provision of false information in the application is a basis for denial of the application.”
(i) Each submitted and signed Part C of Form 2604 “Application for Certification and Enrollment of Home-based Therapeutic Service Providers” (October 2016) shall have the following attestation signed and dated by the executive director or designee:
“I certify that a criminal record check for this individual is completed and on file at the agency.”
(j) The applicant shall submit a signed and dated “Statement of Affirmation” as part of Form 2604 “Application for Certification and Enrollment of Home-based Therapeutic Service Providers” (October 2016), that certifies the following:
“I affirm that all the information contained in this application is true, correct, and complete to the best of my knowledge and belief. I acknowledge that the provision of false information in the application is a basis for denial of application. I understand that DCYF has the right to review the information contained in this application.
I affirm that I will notify DCYF in writing within 10 days of any change in the information contained in this application.
By my signature below, I affirm that I have read and agree to adhere to administrative rule He-C 6339, “Certification for Payment Standards in Home Community Based Service Providers.”
(k) The applicant shall provide the following information with, or in addition, to Form 2604 “Application for Certification and Enrollment of Home-based Therapeutic Service Providers” (October 2016) in (f) above:
1. (1) A copy of a completed, signed, and dated “State of New Hampshire Alternative W-9” (October 2016);
2. (2) A current list of the board of directors including the following for each member of the board:
  1. a. The full name;
  2. b. The office held;
  3. c. The professional affiliation; and
  4. d. The address, telephone, and email address;
3. (3) A copy of the program organizational structure;
4. (4) A copy of the prescribing practitioner’s license;
5. (5) A copy of the professional and general liability insurance certificate(s) for the program;
6. (6) A copy of the program brochure; and
7. (7) A copy of a current resume or curriculum vitae for the program coordinator and clinical supervisor.
(l) Each applicant for therapeutic day treatment services shall complete and submit a signed and dated Form 2605 “Application for Certification and Enrollment of Therapeutic Day Service Providers” (October 2016).
(m) Part C of Form 2605 “Application for Certification and Enrollment of Therapeutic Day Service Providers” (October 2016) shall be signed and dated by each direct service staff and include the following affirmation:
“I declare that all the information contained above is true, correct, and complete to the best of my knowledge and belief. I acknowledge that the provision of false information in the application is a basis for denial of my application.”
(n) Each submitted and signed Part C of Form 2605 “Application for Certification and Enrollment of Therapeutic Day Service Providers” (October 2016) shall have the following attestation signed and dated by the executive director or designee:
“I certify that a criminal record check for this individual is completed and on file at the agency.”
(o) The applicant shall submit a signed and dated “Statement of Affirmation” as part of Form 2605 “Application for Certification and Enrollment of Therapeutic Day Service Providers” (October 2016) that certifies the following:
“I affirm that all the information contained in this application is true, correct, and complete to the best of my knowledge and belief. I acknowledge that the provision of false information in the application is a basis for denial of the application. I understand that DCYF has the right to review the information contained in this application.
I affirm that I will notify DCYF in writing within 10 days of any change in the information contained in this application.
By my signature below, I affirm that I have read and agree to adhere to Administrative Rule He-C 6339, “Certification for Payment Standards for In Home Community Based Service Providers.”
(p) The applicant shall provide the following information with, or in addition to, Form 2605 “Application for Certification and Enrollment of Therapeutic Day Service Providers” (October 2016) in (m) above:
1. (1) A completed, signed, and dated “State of New Hampshire Alternative W-9” (October 2016);
2. (2) A current list of the board of directors including the following for each member of the board:
  1. a. The full name;
  2. b. The office held;
  3. c. The professional affiliation; and
  4. d. The address, telephone, and email address;
3. (3) A copy of the program organizational structure;
4. (4) A copy of the prescribing practitioner license;
5. (5) A copy of the professional and general liability insurance certificate(s) for the program;
6. (6) A copy of the program brochure; and
7. (7) A copy of a current resume or curriculum vitae for the program consultant.
(q) Each applicant for adolescent community treatment services shall complete and submit a signed and dated Form 2602 “Application for Certification and Enrollment of Adolescent Community Treatment Service Providers” (October 2016).
(r) Part C of Form 2602 “Application for Certification and Enrollment of Adolescent Community Treatment Service Providers” (October 2016) shall be signed and dated by each direct service staff and include the following affirmation:
“I declare that all the information contained above is true, correct, and complete to the best of my knowledge and belief. I acknowledge that the provision of false information in the application is a basis for denial of the application.”
(s) Each submitted Part C of Form 2602 “Application for Certification and Enrollment of Adolescent Community Treatment Service Providers” (October 2016) shall have the following attestation signed and dated by the executive director or designee:
“I certify that a criminal record check for this individual is completed and on file at the agency.”
(t) The applicant shall submit a signed and dated “Statement of Affirmation” as part of Form 2602 “Application for Certification and Enrollment of Adolescent Community Treatment Service Providers” (October 2016) that certifies the following:
“I affirm that all the information contained in this application is true, correct, and complete to the best of my knowledge and belief. I acknowledge that the provision of false information in the application is a basis for denial of the application. I understand that DCYF has the right to review the information contained in this application.
I affirm that I will notify DCYF in writing within 10 days of any change in the information contained in this application.
By my signature below, I affirm that I have read and agree to adhere to Administrative Rule He-C 6339, “Certification for Payment Standards for In Home Community Based Service Providers.”
(u) The applicant shall provide the following information with, or in addition to, Form 2602 “Application for Certification and Enrollment of Adolescent Community Treatment Service Providers” (October 2016) in (q) above:
1. (1) A completed, signed, and dated “State of New Hampshire Alternative W-9” (October 2016);
2. (2) A current list of the board of directors including the following for each member of the board:
  1. a. The full name;
  2. b. The office held;
  3. c. The professional affiliation; and
  4. d. The address, telephone, and email address;
3. (3) The organizational structure of the program;
4. (4) A copy of the prescribing practitioner’s license;
5. (5) A copy of the professional and general liability insurance certificate(s) for the program;
6. (6) A copy of the program brochure; and
7. (7) A copy of a current resume or curriculum vitae for the program supervisor.”
(v) Each applicant for individual service option in home provider shall complete and submit a signed and dated Form 2606 “Application for Certification and Enrollment of Individual Service Options (ISO) in Home Providers” (October 2016).
(w) Part C 2606 “Application for Certification and Enrollment of Individual Service Options (ISO) in Home Providers” (October 2016) shall be signed and dated by each direct service staff and affirm, the following:
“I declare that all the information contained above is true, correct, and complete to the best of my knowledge and belief. I acknowledge that the provision of false information in the application is a basis for denial of the application.”
(x) Each submitted and signed Part C of Form 2606 “Application for Certification and Enrollment of Individual Service Options (ISO) in Home Providers” (October 2016) shall have the following attestation signed and dated by the executive director or designee;
“I certify that a criminal record check for this individual is completed and on file at the agency.”
(y) The applicant shall submit a signed and dated “Statement of Affirmation” as part of Form 2606 “Application for Certification and Enrollment of Individual Service Options (ISO) in Home Providers” (October 2016) that certifies the following:
“I affirm that all the information contained in this application is true, correct, and complete to the best of my knowledge and belief. I acknowledge that the provision of false information in the application is a basis for denial of the application. I understand that DCYF has the right to review the information contained in this application.
I affirm that I will notify DCYF in writing within 10 days of any change in the information contained in this application.
By my signature below, I affirm that I have read and agree to adhere to Administrative Rule He-C 6339, “Certification for Payment Standards for In Home Community Based Service Providers.”
(z) The applicant shall provide the following information with or in addition to Form 2606 “Application for Certification and Enrollment of Individual Service Options (ISO) in Home Providers” (October 2016) in (v) above:
1. (1) A completed, signed, and dated “State of New Hampshire Alternative W-9” (October 2016);
2. (2) A current list of the board of directors including the following for each member of the board:
  1. a. The full name;
  2. b. The office held;
  3. c. The professional affiliation; and
  4. d. The address, telephone, and email address;
3. (3) A copy of the organizational structure of the program;
4. (4) A copy of the prescribing practitioner’s license;
5. (5) A copy of the professional and general liability insurance certificate(s) for the program;
6. (6) A copy of the program brochure; and
7. (7) A copy of a current resume or curriculum vitae for the program.

Source. (See Revision Note at part heading for He-C 6339) #9263, eff 9-20-08; ss by #11180, INTERIM, eff 9-19-16, EXPIRES: 3-18-17; ss by #12136, eff 3-18-17