1. (a) Community based in-home service providers shall complete and submit a completed, signed and dated Form 2607 “Review of Continued Certification for In-Home Community-Based Service Providers” (October 2016), as provided by DCYF, within 30 days of receipt.

2. (b) Part C of Form 2607 “Review of Continued Certification for In-Home Community-Based 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.”

3. (c) Each submitted and signed Part C of Form 2607 “Review of Continued Certification for In-Home Community-Based 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 an on file at the agency.”

4. (d) The provider shall submit a signed and dated “Statement of Affirmation” as part of Form 2607 “Review of Continued Certification for In-Home Community-Based 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.””

5. (e) The provider shall provide the following information with, or in addition to Form 2607 “Review of Continued Certification for In-Home Community-Based Service Providers” (October 2016) in (a) above:

   1. (1) A copy of a resume or curriculum for the program coordinator and the executive director;
   2. (2) The organizational structure of the program;
   3. (3) The resume or curriculum vitae for the prescribing practitioner;
   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;

   7. (7) 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;
   8. (8) A completed, signed, and dated “State of New Hampshire Alternative W-9” (October 2016).
6. (f) Agencies that do not submit a signed and dated Form 2607 “Review of Continued Certification for In-Home Community-Based Service Providers” (October 2016) within 30 days of receipt shall have their certification revoked in accordance with He-C 6339.22 and denied payment.
7. (g) Renewal of certification shall be made by filing a signed and dated Form 2607 “Review of Continued Certification for In-Home Community-Based Service Providers” (October 2016) and shall be based on a review and verification of the provider’s compliance with He-C 6339.14 and specific requirements for the service provided.
8. (h) Review of continued certification compliance shall occur every 5 years from date of issue.

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