1. (a) Each applicant for a license shall comply with the requirements of RSA 151:4, I-III, 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” (May 2024), signed by the applicant 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 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. “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 ASC;

   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” if a sole proprietorship or if otherwise applicable;
   4. (4) List of affiliated or related parties;
   5. (5) The applicable fee in accordance with RSA 151:5, payable in cash 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 qualifications of and copies of applicable licenses or certificates for the ASC administrator and medical director;

   7. (7) 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 applicable for an ASC; and
      2. b. For a building under construction, the written approvals required by He-P 812.04(a) shall be submitted at the time of the application based on the local official’s review of the building plans and upon completion of the construction project;
   8. (8) If the ASC uses a private water supply, documentation that the water supply has been tested in accordance with RSA 485 and Env-Dw 702.02, or, if a public water supply is used, a copy of a water bill;
   9. (9) The results of a criminal records check for the applicant(s), licensee if different than the applicant, the administrator and the medical director which shall include a criminal history from the state of New Hampshire;
   10. (10) A copy of the non-conviction attestation as described in He-P 812.18(m)(9) for the administrator and medical director;
   11. (11) The results of the BEAS registry check from the bureau of elderly and adult services for the administrator and medical director; and
   12. (12) 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

Source. #5514, eff 11-25-92; amd by #6530, eff 6-27-97; amd by #6895, INTERIM, eff 11-26-98, EXPIRED: 3-26-99; paragraphs (c) and (d) EXPIRED: 6-27-05 New. #9727-A, eff 6-18-10, EXPIRED: 6-18-18 New. #12557, INTERIM, eff 6-26-18, EXPIRES: 12-24-18 New. #12926, eff 11-26-19; ss by #14042, eff 8-6-24 (formerly He-P 812.04)