Section He-M 1001.20 - Required Forms(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 Individual Day Provider" (1/1/09 edition) .(b) Applicants applying for emergency certification shall: (1) Complete and submit the form entitled "Emergency Certification for Community Residences- 3 or Fewer Beds" (7/1/02 edition); and(2) Include a signature from the provider agency representative and the executive director of the responsible area 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.(c) Forms completed in accordance with (a) or (b) above shall be submitted to: Department of Health and Human Services
Office of Operations Support
Health Facilities Administration
129 Pleasant Street
Concord NH 03301
(d) Applicants or community residences applying for a waiver shall: (1) Complete and submit the form entitled "NH bureau of Developmental Services Waiver Request" (September 2007 edition); and(2) Include a signature from the individual(s) or legal guardian(s) indicating agreement with the request and the area agency's executive director or designee recommending approval of the waiver.N.H. Admin. Code § He-M 1001.20
Amended by Volume XXXVIII Number 45, Filed November 8, 2018, Proposed by #12650, Effective 10/24/2018, Expires 4/22/2028.The amended version of this section by New Hampshire Register Volume 39, Number 37, eff.8/20/2019 is not yet available.
The amended version of this section by New Hampshire Register Number 45, eff. 10/21/2023 is not yet available.