1. (a) Each applicant for a license shall comply with the requirements of RSA 151:4, I-III(a), and submit the following to the department:

   1. (1) A completed application form entitled “Application for Residential, Health Care License or Special Health Care Services” (August 2025), signed by the owner or 2 of the corporate officers, 2 authorized individuals if an association or partnership, or the head of the government agency if a government unit, affirming to the following:

      1. a. “I affirm that I am familiar with the requirements of RSA 151 and the rules adopted thereunder and that the premises are in full compliance. I understand that providing false information shall be grounds for denial, suspension, or revocation of the license, and the imposition of a fine.”; and

      2. b. For any facility required to comply with RSA 151:4-a:

         “I affirm that I have complied with RSA 151:4-a and a determination is on file with the department that finds the proposed health care facility shall be allowed to apply for licensure.”;

   2. (2) A floor plan of the prospective hospital;

   3. (3) If applicable, proof of authorization from the New Hampshire secretary of state to do business in New Hampshire in the form of one of the following:

      1. a. “Certificate of Authority,” if a corporation;
      2. b. “Certificate of Formation,” if a limited liability corporation; or
      3. c. “Certificate of Trade Name,” where applicable;
   4. (4) List of affiliated or related parties;
   5. (5) The applicable fee in accordance with RSA 151:5, payable in cash in the exact amount of the fee or, if paid by check or money order, the exact amount of the fee made payable to the “Treasurer, State of New Hampshire”;
   6. (6) A resume identifying the name and qualifications of the administrator and medical director;
   7. (7) Copies of applicable licenses, certificates, or both, for the administrator and medical director;

   8. (8) Written local approvals as follows:

      1. a. For an existing building, the following written local approvals shall be obtained no more than 90 days prior to submission of the application, from the following local officials, or if there is no such official(s), from the board of selectmen or mayor:

         1. 1. The health officer verifying that the applicant complies with all applicable local health requirements and drinking water and wastewater requirements;
         2. 2. The building official verifying that the applicant complies with all applicable state building codes and local building ordinances;
         3. 3. The zoning officer verifying that the applicant complies with all applicable local zoning ordinances; and
         4. 4. The fire chief verifying that the applicant complies with the state fire code and local fire ordinances for a health care facility; and
      2. b. For a building under construction, the written approvals required by (a) above shall be submitted at the time of the application based on the local official’s review of the building plans and their final inspection upon completion of the construction project;
   9. (9) If the hospital uses a private water supply, documentation that the water supply has been tested in accordance with RSA 485 and Env-Dw 702.02 and Env-Dw 704.02, or if public water supply is used, a copy of a water bill;

   10. (10) A written statement from the applicant, proposed licensee, administrator, and medical director stating that they:

       1. a. Do not have a felony conviction in this or any other state;
       2. b. Have not been convicted of a sexual assault, other violent crime, assault, fraud, abuse, neglect, or exploitation or pose a threat to the health, safety, or well-being of a patient in this or any other state;
       3. c. Do not have any permanent restraining or protective orders against the applicant, licensee, or administrator; and
       4. d. Have not had a finding by the department or any administrative agency in this or any other state for assault, fraud, abuse, neglect, or exploitation of any person in this or any other state;
   11. (11) If any of the items in (10) above have occurred, the individual shall include a detailed explanation of the circumstances surrounding the occurrences;
   12. (12) The results of a criminal records check for the applicant(s), licensee if different than the applicant, administrator, and medical director that shall include a criminal history from the state of New Hampshire;
   13. (13) The results of a BEAS registry check from the bureau of elderly and adult services for the administrator and medical director: and
   14. (14) Any waiver requests, if applicable.

2. (b) The applicant shall mail or hand-deliver the documents to:

   Department of Health and Human Services

   Office of Legal and Regulatory Services

   Health Facilities Administration

   129 Pleasant Street

   Concord, NH 03301

3. (c) If a hospital has not previously performed a special health care service but plans to do so, the hospital shall complete a new application including all of the above application requirements and any information required under He-P 802.39, He-P 802.40, and He-P 802.41.
4. (d) A previously operating special health care service, which means a special health care service as defined by RSA 151:2-e, II that was being offered by a hospital prior to July 1, 2016 and has continued to be offered since July 1, 2016, shall not require additional licensure separate from the hospital license but shall still comply with RSA 151 and all applicable He-P 802 provisions.

Source. #2044, eff 6-3-82; ss by #3193, eff 1-28-86, EXPIRED: 1-28-92; ss by #5317, EMERGENCY, eff 1-29-92, EXPIRED: 5-28-92 New. #5846, eff 6-22-94, EXPIRED: 6-22-00 New. #9580, eff 10-24-09; ss by #12407, INTERIM, eff 10-24-17, EXPIRED: 4-22-18 New. #13166, eff 1-28-21; ss by #14081, eff 9-25-24, EXPIRES: 9-25-34 (formerly He-P 802.04)