N.H. Admin. Code § Ve-H 306.01

Current through Register No. 50, December 12, 2024

Section Ve-H 306.01 - Application Procedures

(a) Applicants for residency or their legal representatives shall apply by completing and submitting an application packet consisting of the application pages described in (b) below and the documents described in (c) below.

(b) The applicant shall provide the following:

(1) On page one, "NH veterans' home admission application" (effective date 07/16/18), requesting the following types of information:

a. Personal;

b. Military service; and

c. Some medical and medical insurance;

(2) Page one-A, "Legal and Contact Information" (effective date 03/17/08):

a. The following types of information:

1. Whether the applicant has executed specified legal documents;

2. Whether the applicant is under guardianship or conservatorship; and

3. Information about the applicant's spouse and contact persons; and

b. A witnessed signature and the date of signing;

(3) Page 2, "Final Requests" (revised date 3/10/10), requesting information about arrangements in case of demise;

(4) Page 3A, "Applicant's Financial Affidavit for NHVH" (effective date 07/16/18), requesting:

a. The applicant's and the applicant's spouse's separate assets;

b. Their joint assets;

c. The applicant's alimony and child support obligations;

d. Information about the applicant's long term care insurance; and

e. The applicant's and the applicant's spouse's income from specified sources;

(5) Page 4, "New Hampshire Veterans' Home Agreement Form" (effective date 3/17/08), requiring below a preprinted statement:

a. The witnessed signature of the applicant or the applicant's legal representative; and

b. The date of signing;

(6) Page 5A, "State Home Program Application For Veteran Care Medical Certification" (VA Form 10-10SH Sep 2016), requiring completion by the applicant's physician;

(7) Page 5B, "New Hampshire Veterans Home Medical Information Form" (revised date 03/17/08), requiring completion by the applicant's physician and faxing of pertinent test results;

(8) Page 6, "release of information" (effective date 10/19/17):

a. Giving the applicant's permission for the medical providers and institutions indicated to:

1. Furnish to the home a copy of the signer's medical record;

2. Allow the home to review the medical record; and

3. Furnish to the home specified additional pieces of information; and

b. Including:

1. The witnessed signature of the applicant or the applicant's legal representative; and

2. The date of signing;

(9) Page 8, "consent to treatment, use of health care information, and receipt of privacy notice" (effective date 03/17/08), requiring:

a. The initials of the applicant or the applicant's legal representative placed next to 3 preprinted statements entitled respectively "consent for care and treatment", "consent for use of health care information" and "acknowledgement of receipt of privacy notice;

b. The signature of the applicant or the applicant's legal representative; and

c. The date of signing;

(10) Page 9, "New Hampshire veterans' home security form" (effective date 07/16/18) requiring:

a. Written information about any non-annulled conviction;

b. The witnessed signature of the applicant or the applicant's legal representative; and

c. The date of signing; and

(11) On the last page, un-numbered, a completed "Criminal History Record Information Release Authorization" from the department of safety (revised date 07/15/16) issued by the division of state police authorizing the release of the applicant's criminal record.

(c) Applicants for residency or their legal representatives shall submit or arrange for the following documents to be submitted:

(1) The completed form which is page 5A of the application packet, entitled "state home program application for veteran care medical certification" (effective date 07/16/18);

(2) The completed form which is page 5B of the application packet, entitled "medical information for nhvh admission application" (effective date 03/17/18);

(3) Original military documents showing:

a. Entry into service;

b. Discharge from service; and

c. The type of discharge from service;

(4) Photocopies of all cards issued to the applicant by providers of medical insurance, including Medicare;

(5) Photocopies of the applicant's:

a. Living will;

b. Powers of attorney for health care or finances; and

c. Any other documents addressing his or her advance directives;

(6) Photocopies of any legal orders establishing a guardianship or conservatorship over the applicant;

(7) The applicant's certified marriage certificate or certified divorce decree;

(8) Documentation of all assets held at any time during the 12 months immediately prior to the date of application, including:

a. Trust documents;

b. Annuity documents;

c. Deeds and related mortgage documents;

d. Long term care insurance policies;

e. Stock certificates and other evidence of investments; and

f. Any other documents showing the applicant's ownership of assets; and

(9) Documentation of all income received during the 12 months immediately prior to the date of application, including:

a. Photocopies of checks in payment of:

1. Social security;

2. Disability insurance;

3. Railroad retirement;

4. Military retirement;

5. Pensions;

6. Salary or compensation;

7. Rents charged by the applicant;

8. Interest on the applicant's investments; and

9. Any other periodic payment;

b. Statements issued in connection with the payments listed in a. above; or

c. Bank statements showing direct deposit of the payments listed in a. above.

N.H. Admin. Code § Ve-H 306.01

#8953, eff 7-21-07

Amended by Volume XXXIX Number 06, Filed February 7, 2019, Proposed by #12711, Effective 1/15/2019, Expires 1/15/2029.