Section He-E 804.03 - Application Requirements(a) The NA shall complete an application, form BEAS 292 "Application for Reimbursement for Nursing Assistant Training and Competency Testing," in full that includes the following: (1) The NA's contact information, including: a. Name, current mailing address, and telephone number; and(2) The name of the nursing facility where the NA is or was employed or has received an offer of employment from;(3) The amount requested for training program reimbursement;(4) The start and completion dates of the training program or the date of the competency test;(5) The name of the agency or entity that provided the training program; (6) A disclosure statement indicating whether the NA paid for the entire training program or shared the cost of the training program with a third party and if applicable, the amount paid by the third party;(7) The NA's original signature as the applicant and the date of signature, attesting that the information provided in Section A of the application is accurate and that the applicant is, has been, or will be employed by the nursing facility named; and(8) An attached, legible receipt from the agency that provided the training or competency testing, or the entity that processed the payment, that documents proof of payment by the NA. The receipt shall contain the NA's name, the title or description of the NA training program taken, and the amount(s) that the NA paid for the training program or competency testing.(b) If a third party is seeking reimbursement for paying for a NA's training, the third party shall provide the following on or with the application: (1) The name, phone number, and address of the third party;(2) The amount requested for training program reimbursement;(3) The third party's original signature and date of signature attesting that the information provided in Section B of the application is accurate that the third party has paid the amount listed (b)(2) above for nursing assistant training of the applicant; and(4) An attached, legible receipt from the agency that provided the training or competency testing, or the entity that processed the payment, that documents proof of payment by the third party. The receipt shall contain the third party's name, the title or description of the NA training program taken, and the amount(s) that the third party paid for the training program or competency testing.(c) The NA or third party shall submit the documentation required in (a) above and (b) above if applicable to the administrator of the employing nursing facility.(d) The nursing facility administrator shall complete the following on the application:(1) The name, phone number, and license number of the nursing facility; (2) The name of the applicant and date that the applicant was hired as an NA or the date the applicant will start after receiving an offer of employment as an NA;(3) Whether the applicant is currently, was formerly, or will be employed at the nursing facility; and (4) The nursing facility administrator's printed name and dated signature.(e) The nursing facility administrator shall forward the application to the NH board of nursing by mailing it to: New Hampshire Board of Nursing Nurse Aide Registry
7 Eagle Square
Concord, NH 03301-2431.
(f) The NH board of nursing nurse aide registry shall:(1) Certify, by dated signature on the application, that records indicate that the named NA has successfully completed an approved NH training program or competency testing within 12 months prior to the date of hire or offer of employment, and that the NA has been duly certified and registered by the NH board of nursing nurse aide registry, by providing the NA's registry number; and(2) Submit the completed application to the department by mailing it to: The Department of Health and Human Services
Office of Finance
105 Pleasant Street
Concord, NH 03301-3857.
N.H. Admin. Code § He-E 804.03
#7752, eff 8-17-02, EXPIRED: 8-17-10
New. #9769-B, eff 8-25-10
Amended by Volume XXXIX Number 6, Filed February 7, 2019, Proposed by #12717, Effective 1/26/2019, Expires 1/26/2029.Amended by Volume XLI Number 32, Filed August 12, 2021, Proposed by #13242, Effective 7/24/2021, Expires 7/24/2031.