Section He-P 812.04 - Initial License Application Requirements(a) Each applicant for a license shall comply with the requirements of RSA 151:4II, I-I, and submit the following to the department: (1) A completed application form entitled "Application for Residential, Health Care License or Special Health Care Services" (March 2019) , signed by the applicant or 2 of the corporate officers affirming 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 the license, and the imposition of a fine.";b. For any ACS to be newly licensed: "I certify that I have notified the public of 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 ten (10) business days prior to the filing of this application";
c. For any ASC to be newly licensed and to be located within a radius of fifteen (15) miles of a hospital as a critical access hospital, pursuant to 42 C.F.R. 485.610(b) and (c) : "I certify that the facility is to be located within a radius of fifteen (15) miles of a hospital as a critical access hospital, pursuant to 42 C.F.R. 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 ten (10) business days prior to the filing of this application."; and
d. For facilities to be licensed under the listed categories: "I understand that, in accordance with RSA 151:4, III(a) (7) , this facility cannot be licensed pursuant to He-P 802, 806, 810, 811, 812, 816, 823, or 824 if it is within a radius of 15 miles of a hospital certified as a critical access hospital, pursuant to 42 C.F.R 485.610(b) and (c) , until the Commissioner makes a determination that the proposed new facility will not have a material adverse impact on the essential health care services provided in the service area of the critical access hospital. I also understand that if the Commissioner is not able to make such a determination, the license will not be issued."
(2) A floor plan of the prospective ASC;(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: a. "Certificate of Authority" if a corporation;b. "Certificate of Formation" if a limited liability corporation; orc. "Certificate of Trade Name" if a sole proprietorship or if otherwise applicable;(4) 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";(5) A resume identifying the name and qualifications of the ASC administrator and medical director;(6) Copies of applicable licenses and/or certificates for the ASC 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 applicable local zoning ordinances; and4. The fire chief verifying that the applicant complies with the state fire code, Saf-C 6000, and as amended pursuant to RSA 153:5, I by the state fire marshal with the board of fire control, including but not limited to the ambulatory health care occupancy chapter of NFPA 101 as adopted by the commissioner of the department of safety, and local fire ordinances applicable for an ASC; and 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) 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; and(9) The results of a criminal records check from the NH department of safety for the applicant(s), licensee if different than the applicant, the administrator, and the medical director, as applicable.(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
N.H. Admin. Code § He-P 812.04
#5514, eff 11-25-92; amd by #6530, eff 6-27-97; amd by #6895, INTERIM, eff 11-26-98, EXPIRED: 3-26-99; paragraph (e) EXPIRED: 6-27-05
New. #9727-B, eff 6-18-10
Amended by Volume XXXVIII Number 28, Filed July 12, 2018, Proposed by #12557, Effective 6/26/2018, Expires 12/24/2018.Amended by Volume XXXIX Number 50, Filed December 12, 2019, Proposed by #12926, Effective 11/26/2019, Expires 11/26/2029.