1. (a) Applicants or community residences applying for an initial or renewal certification shall complete and submit the form entitled “Request for Certification of Community Residence and/or Community Participation Services Provider” (May 2025).

2. (b) Applicants applying for emergency certification shall:

   1. (1) Complete and submit the form entitled “Emergency Certification for Community Residence- 3 or Fewer Beds” (May 2025) certifying the following:

      “I Certify that:

      A. (Individual’s name), born on (date of birth) needed immediate placement on (date) to protect his/her health and safety because ______________________________________.

      B. There is no condition within the above residence that would pose a health or safety threat to the client.

      C. This residence is in full compliance with the statutes and regulations governing Community Residences.”; and

   2. (2) Include a signature from the executive director of the responsible provider agency that verifies that the appropriate staff determined that the home meets the requirements of He-M 503, He-M 522, He-M 1001, He-M 1201, and He-M 507, as applicable.

3. (c) Forms completed in accordance with (a) or (b) above shall be submitted to the department via:

   1. (1) Email at communityresidences@dhhs.nh.gov;
   2. (2) By fax to (603) 271-4968; or

   3. (3) By mail to:

      Department of Health and Human Services

      Office of Legal and Regulatory Services

      Health Facilities Administration

      129 Pleasant Street

      Concord NH 03301

4. (d) Applicants or community residences applying for a waiver shall:

   1. (1) Complete and submit the form entitled “NH Bureau of Developmental Services Waiver Request” (October 2023); and

   2. (2) Include a signature from the individual(s) or legal guardian(s) indicating agreement with the request and the provider agency’s executive director or designee recommending approval of the waiver, when the waiver is requested by a provider agency, and be submitted to the department via:

      1. a. Email at bds@dhhs.nh.gov;
      2. b. Fax to (603) 271-5166; or

      3. b. By mail to:

         The Bureau of Developmental Services

         Hugh J. Gallen State Office Park

         105 Pleasant Street, Main Building

         Concord, NH 03301

Source. #9776-B, eff 10-1-10; ss by #12650, INTERIM, eff 10-24-19, EXPIRED: 4-22-19 New. #12775, eff 5-7-19; ss by #14255, eff 5-23-25, EXPIRES: 5-23-35