N.H. Admin. Code § Agr 2803.02

Current through Register No. 45, November 7, 2024

Section Agr 2803.02 - Owner Application for Sterilization of a Dog or Cat

(a) The "Application for Sterilization of a Dog or Cat" form shall be filled out by the companion animal's owner who is receiving aid under one of the programs listed in Agr 2801.02(a).

(b) The companion animal's owner shall provide the following in Part 1 - Client/Pet Information section of the application form:

(1) Name, address, and phone number of applicant;

(2) Program under which eligibility is claimed in accordance with RSA 437-A:3, I;

(3) The following regarding the animal:

a. Name;

b. Species;

c. Breed;

d. Sex;

e. Age; and,

f. Weight;

(4) Signature of applicant and date signed; and

(5) That the applicant consents to the following:

a. Immunizations if required;

b. Sterilization of the pet described above;

c. That the information above is true and correct to the best of the applicant's knowledge; and

d. That the applicant authorizes the department of health and human services, division of family assistance and/or social security administration to release eligibility verification for one of the programs in Agr 2801.02(a) to the administrator.

(c) After the application form is completed, the applicant shall:

(1) Send the application form; and

(2) The proof of eligibility required under Agr 2802.01 to the administrator for approval.

(d) An applicant shall be notified of an incomplete application at the time of receipt by the program administrator in accordance with RSA 541-A:29 and said application shall be deemed abandoned when the applicant fails to supply the documents required under Agr 2802.01 within 60 days of the program administrator's initial notice of additional required information. Applicant may not reactivate an abandoned application but can reapply by filling out another owner Application for Sterilization of a Dog or Cat and complying with the requirements of Agr 2802.01.

(e) Upon review by the administrator, if an applicant meets the requirements of Agr 2802.01, then the administrator shall:

(1) Sign and date Part 2 - Certification by Program Administrator section of the form certifying approval was granted; and

(2) Mail the form back to the applicant.

(f) An approved application shall only remain valid until both the calendar and fiscal years in which it was issued have ended. For example, an application approved in May shall remain valid after the close of the fiscal year on June 30th, but shall expire on December 31st when the calendar year has ended.

(g) Upon return receipt of the form from the administrator, the applicant shall submit the form and the co-payment as required by RSA 437-A:3, I to the participating veterinarian performing the companion animal's sterilization procedure.

(h) The participating veterinarian shall:

(1) Provide the following in Part 3 - Veterinarian Information section of the form:

a. Name of participating veterinarian;

b. Address of participating veterinarian's office;

c. Telephone number of participating veterinarian's office;

d. Date of surgery;

e. Types of vaccinations administered and date;

f. Acknowledgement that the co-payment was received from or on behalf of the applicant for the sterilization;

g. Certification that the sterilization and/or immunizations of the animal above was carried out as recorded;

h. Signature of veterinarian that performed the surgery and date; and

i. Obtain applicant's signature and date verifying that the sterilization surgery was completed; and

(2) Submit the form to the administrator at the address on the form within 10 days following the end of the monthly period after retaining the copy designated for the payee at the bottom of the form.

N.H. Admin. Code § Agr 2803.02

#5840, eff 6-17-94; ss by #6786, eff 7-1-98, EXPIRED: 7-1-06

New. #10568, eff 4-18-14