Section He-P 810.04 - License Application Requirements(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) A completed application form entitled "Application for Residential or Health Care License" (8/4/2016 edition), signed by the applicant or 2 of the corporate officers, affirming and certifying the following: 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 a license, or imposition of a fine.";b. For any birthing center to be newly licensed on or after July 1, 2016: "I certify that I have notified the public of the intent to file this application with a description of the facility to be licensed by publishing a notice in a newspaper of general circulation covering the area where the facility is to be located in at least 2 separate issues of the newspaper no less than 10 business days prior to the filing of this application."; and
c. For any birthing center to be newly licensed on or after July 1, 2016 and to be located within a radius of 15 miles of a hospital certified as a critical access hospital, pursuant to 42 C.F.R. section 485.610(b) and (c) : "I certify that the facility is to be located within a radius of 15 miles of a hospital certified as a critical access hospital, pursuant to 42 C.F.R. section 485.610(b) and (c) , and that I have given written notice of the intent to file this application with a description of the facility to be licensed to the chief executive officer of the hospital by registered mail no less than 10 business days prior to the filing of this application."
(2) A floor plan of the prospective birthing center including the location of all beds;(3) Proof of authorization from the New Hampshire secretary of state to do business in New Hampshire in the form of one of the following: a. "Certificate of Authority," if a corporation;b. "Certificate of Formation," if a limited liability corporation; orc. "Certificate of Trade Name," where applicable;(4) The applicable $150.00 fee, in accordance with RSA 151:5, XXI, payable in cash or, if paid by check or money order, in the exact amount of the fee, made payable to the "Treasurer, State of New Hampshire;"(5) A resume identifying the name and qualifications of the birthing center administrator and medical director;(6) Copies of applicable licenses, certificates, or both, for the birthing center administrator and medical director;(7) Written local approvals as follows: 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. The health officer verifying that the applicant complies with all applicable local health requirements and drinking water and wastewater requirements;2. The building official verifying that the applicant complies with all applicable state building codes and local building ordinances;3. The zoning officer verifying that the applicant complies with all local applicable zoning ordinances; and4. The fire chief verifying that the applicant complies with the state fire code, including the ambulatory health care chapter of National Fire Protection Association (NFPA) 101 as adopted by the department of safety, and local fire ordinances applicable for a birthing center; orb. 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 again upon completion of the construction project;(8) If the birthing center uses a private water supply, documentation that the water supply has been tested in accordance with RSA 485 and Env-Dw 702.02 and 704.02, or if a public water supply, a copy of a water bill; and(9) For a birthing center to be newly licensed on or after July 1, 2016, and to be located within a radius of 15 miles of a hospital certified as a critical access hospital, pursuant to 42 C.F.R. section 485.610(b) and (c) , a letter from the chief executive officer of the hospital stating that the proposed new birthing center will not have a material adverse impact on the essential health care services provided in the service area of the critical access hospital.(b) The applicant shall mail or hand-deliver the documents to: Department of Health and Human Services
Health Facilities Administration
129 Pleasant Street
Concord, NH 03301
N.H. Admin. Code § He-P 810.04
#5635, eff 6-7-93; ss by #7006, INTERIM, eff 5-26-99, EXPIRED: 9-23-99
New. #8957, eff 7-27-07
Amended by Volume XXXVI Number 36, Filed September 8, 2016, Proposed by #11161, Effective 8/20/2016, Expires 8/20/2026.