1. (a) Any residential treatment program licensed in accordance with RSA 170-E or RSA 151, or from another state, that seeks certification in accordance with He-C 6350 shall request application Form 2601 “Certification for Payment Application – Residential Programs” (January 2026) from BCBH and be supported by a need identified by the department in accordance with RSA 170-G:4 and RSA 169-F.

2. (b) The application form in (a) above shall be completed, signed, and dated by the residential program’s executive director, or designee, affirming the following:

   “I have reviewed RSA 126-U, RSA 135-F:3(e), the Administrative Rules He-C 6350 and He-C 6420 and will adhere to the rules as a certified provider. I authorize the Bureau for Children’s Behavioral Health (BCBH) to conduct a certification for payment review to determine the program’s compliance with Administrative Rules He-C 6350 and He-C 6420. I authorize BCBH to access the program for the purpose of Certification and the NH Division for Children, Youth and Families (DCYF) to access the program and children referred by DCYF in accordance with RSA 169-F. I further understand that BCBH has the right to verify information contained in this application.”; and

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

3. (c) The completed application form in (a) above shall be emailed to the department within 90 days of receipt to ChildrensResidentialCertification@dhhs.nh.gov.

4. (d) The applicant shall provide the following information with, or in addition to, the application form in (a) above:

   1. (1) Evidence that the board of directors has approved the certification request which may include but is not limited to minutes of the board meeting documenting that the request was approved or a signature of the board’s president;
   2. (2) The names of the residential staff or child care personnel within the program;
   3. (3) An electronic copy of the program description, including a description of the services provided to children and their families, as well as a description of the daily milieu, and how the program promotes the safety, permanency, and well-being of children and their families, adheres to the system of care values, including any specialized services that are supported by any certifications or accreditations, or both;
   4. (4) An electronic copy of Form 2626 “Residential Program Summary” (January 2026) which is an abbreviated program description that can be provided to the court to support placement decision making in accordance with RSA 169-F:8;
   5. (5) The name, office held, professional affiliation, address, and telephone numbers of each person on the program’s board of directors, including whether or not the board member is a present or past recipient of the agency’s services;

   6. (6) A copy of the program’s license or operational approval, in accordance with the following:

      1. a. For programs in New Hampshire, a copy of the license issued in accordance with RSA 170-E:31 or RSA 151:5; or
      2. b. For programs outside of New Hampshire, documentation of approval from the corresponding state’s regulatory agency(ies);
   7. (7) A general liability certificate of insurance for the program;
   8. (8) An electronic copy of Form CBH007 “Qualified Residential Treatment Program Checklist (January 2026);
   9. (9) Organizational information which shall include an organizational chart with personnel titles or positions with the identification of the individuals in those roles, including identification of who in the program is responsible for implementation of reasonable and prudent parent standards. Job descriptions, and the corresponding credentials for those individuals who are meeting the requirements of He-C 6350.11 which shall include the education and experience requirements in He-C 6350.11, as applicable;

   10. (10) Educational certification, in accordance with the following:

       1. a. For programs in New Hampshire which operate and maintain approval as a non-public school pursuant to Ed 400 and a private provider of special education provider pursuant to Ed 1100, a copy of their approval from the New Hampshire state board of education; or
       2. b. For programs outside of New Hampshire with education programs, documentation of educational certification from the corresponding state’s regulatory agency(ies);
   11. (11) The name and contact information for the state’s licensing body and the contact information for the accreditation body;
   12. (12) The staff training plan, including descriptions of orientation and ongoing training, including trauma training requirements as stated in He-C 6350.11;
   13. (13) An electronic copy of the program’s policies required by He-C 6350.10 and any other policies maintained by the program; and
   14. (14) The program’s restraint and seclusion plan, if accredited and required by the accreditation body.
5. (e) The program administration and staff shall facilitate a tour of the facility for the department’s certification team to conduct a review of all appropriate spaces and certification criteria if necessary.
6. (f) For residential treatment programs seeking recertification, the executive director shall be notified in writing by the department of the need to apply for recertification 4 months prior to the expiration date of the current certification and failure to receive notice shall not relieve any program of the obligation to renew its certification and comply with RSA 170-G and this part.
7. (g) If a program does not receive a notice or renewal application as referenced above in (f), the program shall contact department at ChildrensResidentialCertification@dhhs.nh.gov to obtain a renewal application.
8. (h) The executive director or designee shall complete, sign, and date Form 2601 “Certification for Payment Application – Residential Programs” (January 2026) and indicate that it is for the purpose of recertification.
9. (i) The completed recertification application form in (h) above and information in (b)-(d) above shall be electronically submitted to the department within 30 days of receipt by email to ChildrensResidentialCertification@dhhs.nh.gov.

10. (j) The applicant shall provide the recertification and all information included in (b)-(d) above, with the exception of (d)(1), in addition to (h) above according to Form 2601 “Certification for Payment Application – Residential Programs” (January 2026). The recertification attachments shall also include:

    1. (1) The names of the programs residential staff referenced in (d)(2) above shall only require the names of newly hired staff since the initial certification or most recent recertification, as applicable;
    2. (2) Items in (d)(12), (d)(13), and (d)(14) above only if there are changes since the initial certification or last recertification; and
    3. (3) In (d)(9) only the organizational chart with personnel tittles or positions with the identification of the individuals in those roles, unless He-C 6350.09 requires the job descriptions or corresponding credentials to be supplied at recertification.

Source. #4442, eff 7-1-88; amd by #4906, eff 8-10-90; amd by #5122, eff 4-25-91, EXPIRED 4-25-97 New. #6617, eff 10-25-97; ss by #8453, INTERIM, eff 10-25-05, EXPIRED: 4-23-06 New. #8693, eff 7-27-06; ss by #10759, eff 1-17-15; amd by #12609, eff 8-23-18; ss by #14178, INTERIM, eff 1-18-25; ss by #14490, eff 1-22-26, EXPIRES: 1-22-36