1. (a) Applicants who seek initial certification for payment standards for community-based behavioral health services shall only be referred by a DCYF district office supervisor or designee.

2. (b) If the request is approved, DCYF shall forward an application packet to the applicant, which includes:

   1. (1) A Form 2617 “Application For Certification And Enrollment Of Private Behavioral Health Service Providers” (October 2016);
   2. (2) “State of New Hampshire Alternate W-9 Form”; and
   3. (3) A copy of He-C 6344.

3. (c) Each applicant shall complete, sign, date, and submit a Form 2617 “Application For Certification And Enrollment Of Private Behavioral Health Service Providers”(October 2016); and the following information:

   1. (1) A signed and dated “Statement of Affirmation” as part of Form 2617 “Application For Certification And Enrollment Of Private Behavioral Health Service Providers” (October 2016) that states the following:

      “I have reviewed Administrative Rule He-C 6344 and will adhere to the rules as an enrolled provider. I understand that DCYF has the right to verify information contained in this application”;

      “I will notify DCYF in writing within ten business days of any change to the information contained in this application”;

      “I understand and agree that any individual whom provides services or agency that I subcontract with will have a current and valid license for the service being provided”; and

      “The information contained in this application is correct to the best of my knowledge”.

   2. (2) The applicant shall provide the following information with, or in addition to, Form 2617 “Application For Certification And Enrollment Of Private Behavioral Health Service Providers”(October 2016) in (1) above:

      1. a. A copy of the applicant’s state license to practice or operate;
      2. b. A completed, signed, and dated “State of New Hampshire Alternate W-9 Form”;
      3. c. A resume or curriculum vitae; and
      4. d. A sample of a treatment plan.

4. (d) In addition to the information requested in (c) above, the applicant shall complete, sign, date, and submit the attestation in Part E of Form 2617 “Application For Certification And Enrollment Of Private Behavioral Health Service Providers” (October 2016) that states:

   “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”.

5. (e) Each applicant shall complete, sign, date, and submit a “Statement of Affirmation” as part of Form 2617 “Application For Certification And Enrollment Of Private Behavioral Health Service Providers” (October 2016) that states the following:

   “I have reviewed Administrative Rule He-C 6344 and will adhere to the rules as an enrolled provider. I understand that DCYF has the right to verify information contained in this application”;

   “I will notify DCYF in writing within ten business days of any change to the information contained in this application”;

   “I understand and agree that any individual whom provides services or agency that I subcontract with will have a current and valid license for the service being provided”; and

   “The information contained in this application is correct to the best of my knowledge”.

Source. (See Revision Note at part heading for He-C 6344) #9311, eff 11-5-08; ss by #12206, eff 6-10-17 (from He-C 6344.08)