1. (a) Private providers shall complete, sign, date, and submit a Form 2617R “Certification Renewal - Private Behavioral Health Providers” (October 2016), as provided by DCYF, within 30 days of receipt and include the following information:

   1. (1) A completed, signed, and dated “Statement of Affirmation” as part of Form 2617R “Certification Renewal - Private Behavioral Health 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 10 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 2617R “Certification Renewal - Private Behavioral Health Providers” (October 2016):

      1. a. License to practice or operate; and
      2. b. “State of New Hampshire Alternate W-9 Form”.

   3. (3) In addition to the information requested in (a) and (b) above the applicant shall complete, sign, date, and submit the attestation in Part C of Form 2617R “Certification Renewal - Private Behavioral Health 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.”

2. (b) Private providers who fail to complete and submit a Form 2617R “Certification Renewal - Private Behavioral Health Providers” (October 2016) within 30 days of receipt shall have their certification revoked in accordance with He-C 6344.23 and be denied payment.
3. (c) Continuance of certification shall be based on a review and verification of the provider’s compliance with He-C 6344.
4. (d) Private provider applicants shall submit a copy of the documentation required by the appropriate state licensing board or boards to DCYF at the time of license renewal to DCYF.
5. (e) Private provider applicants shall submit a copy of their renewed license to DCYF.
6. (f) Review of continued certification shall coincide with the date of expiration of the private provider’s applicable state licensing board(s).
7. (g) In the event of dual licensing the date of the earliest license expiration will be used.

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 6344.11)