"Application for Individual Home Care Service Provider Registration" - New Hampshire

Application for Individual Home Care Service Provider Registration is a legal document that was released by the New Hampshire Department of Health and Human Services - a government authority operating within New Hampshire.

Form Details:

  • Released on June 8, 2016;
  • The latest edition currently provided by the New Hampshire Department of Health and Human Services;
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Download "Application for Individual Home Care Service Provider Registration" - New Hampshire

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STATE OF NEW HAMPSHIRE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OFFICE OF LEGAL AND REGULATORY SERVICES
HEALTH FACILITIES ADMINISTRATION
129 Pleasant Street, Concord, NH 03301
TDD Access: Relay NH 1-800-735-2964
Agency Phone: 603-271-9039
APPLICATION FOR INDIVIDUAL HOME CARE SERVICE PROVIDER REGISTRATION
REGISTRATION #: ______________
EXPIRATION DATE: _____________________
THIS APPLICATION SHALL BE FILLED OUT IN ACCORDANCE WITH RSA 151:4. PLEASE BE SURE TO
COMPLETE THE ENTIRE APPLICATION. IF A SECTION DOES NOT APPLY TO YOUR FACILITY MARK
NOT APPLICABLE (N/A). FAILURE TO COMPLETE THE APPLICATION WILL RESULT IN A DELAY IN THE
REGISTRATION PROCESS. SEND THE COMPLETED FORM TO THE ADDRESS ABOVE.
Check all applicable items:
Renewal:
Change in address:
Other (please explain):
New
NAME : ________________________________________________________TELEPHONE #: (___)___________
FAX #: (___)___________
STREET ADDRESS:______________________________CITY:______________STATE:____ZIP:________
MAILING ADDRESS:_____________________________CITY:______________STATE:____ZIP:________
E-MAIL ADDRESS________________________________________________________________
OWNERSHIP
a.
Type of ownership:
LLC:
Individual:
FEES: (EFFECTIVE JULY 1, 2013)
Personal Care Providers (820)
Less than 10 clients $25.00, Ten or More clients $250.00
A check or money order (payable to: STATE OF NEW HAMPSHIRE, TREASURER), must be attached to
this application.
Applications submitted by those facilities exempt under RSA 151:4 are not required to pay the license fee.
INDIVIDUAL HOME CARE SERVICE PROVIDER APPLICATION
6/8/2016
STATE OF NEW HAMPSHIRE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OFFICE OF LEGAL AND REGULATORY SERVICES
HEALTH FACILITIES ADMINISTRATION
129 Pleasant Street, Concord, NH 03301
TDD Access: Relay NH 1-800-735-2964
Agency Phone: 603-271-9039
APPLICATION FOR INDIVIDUAL HOME CARE SERVICE PROVIDER REGISTRATION
REGISTRATION #: ______________
EXPIRATION DATE: _____________________
THIS APPLICATION SHALL BE FILLED OUT IN ACCORDANCE WITH RSA 151:4. PLEASE BE SURE TO
COMPLETE THE ENTIRE APPLICATION. IF A SECTION DOES NOT APPLY TO YOUR FACILITY MARK
NOT APPLICABLE (N/A). FAILURE TO COMPLETE THE APPLICATION WILL RESULT IN A DELAY IN THE
REGISTRATION PROCESS. SEND THE COMPLETED FORM TO THE ADDRESS ABOVE.
Check all applicable items:
Renewal:
Change in address:
Other (please explain):
New
NAME : ________________________________________________________TELEPHONE #: (___)___________
FAX #: (___)___________
STREET ADDRESS:______________________________CITY:______________STATE:____ZIP:________
MAILING ADDRESS:_____________________________CITY:______________STATE:____ZIP:________
E-MAIL ADDRESS________________________________________________________________
OWNERSHIP
a.
Type of ownership:
LLC:
Individual:
FEES: (EFFECTIVE JULY 1, 2013)
Personal Care Providers (820)
Less than 10 clients $25.00, Ten or More clients $250.00
A check or money order (payable to: STATE OF NEW HAMPSHIRE, TREASURER), must be attached to
this application.
Applications submitted by those facilities exempt under RSA 151:4 are not required to pay the license fee.
INDIVIDUAL HOME CARE SERVICE PROVIDER APPLICATION
6/8/2016
INDIVIDUAL HOME CARE SERVICE PROVIDER APPLICATION
PAGE 2
APPLICATION SHALL INCLUDE:
1.
Be submitted at least 120 days prior to expiration of the current registration. (Yearly)
2.
Attach qualifications, including education, experience and copies of all applicable licenses for the administrator.
(Initial)
3.
Secretary of State Information. (Initial-if applicable)
4.
Results of Criminal Background Check. (Initial)
5.
Results of State registry check through Bureau of Elderly and Adult services pursuant to RSA 161-F:49. (Initial)
FACILITY SERVICE DESCRIPTION:
The following information will be used to determine which category your facility shall be placed in.
I.
Provide a detailed description of the services and programs you wish to provide.
SIGNATURES:
This application must be signed by:
1.
The Individual Home Care Service Provider.
“I affirm that I am familiar with and in full compliance with the provisions of RSA 151:2,v and He-P 820. I also affirm
that I have not been convicted of a felony in this or any other state, have not been convicted for sexual assault, other
violent crime, assault, fraud, abuse, neglect, exploitation or any other criminal offense that suggests that they may pose a
threat to the health, safety or well-being of a client, and have not been found to have to committed assault, fraud, abuse,
neglect or exploitation by the department or any other administrative agency in this or any other state. I understand that
providing false information shall be grounds for denial or revocation of the registration and the imposition of a fine.”
“Advisory: The New Hampshire Department of Health and Human Services is authorized to require all licensed home
care providers to read and understand the Home Care Clients’ Bill of Rights set forth in RSA 151:21-b, and to distribute
the law to all of their clients. The Department recommends that all individual home care service providers read and
understand the Home Care Clients’ Bill of Rights and share the information with their clients.”
DATE: _________________ SIGNED: _______________________________________________________
(NAME AND TITLE)
INDIVIDUAL HOME CARE SERVICE PROVIDER APPLICATION
6/8/2016
INDIVIDUAL HOME CARE SERVICE PROVIDER APPLICATION
PAGE 3
BHFA OFFICE USE ONLY
CHECK NUMBER: _______________
AMOUNT: _________________________
APPLICATION COMPLETE: _______
NOT COMPLETE: ___________________
(Describe in comments)
NEW
RENEWAL
CHANGE
QUALIFICATIONS OF ADMINISTRATOR
Required
Not Required
Received
SECRETARY OF STATE INFORMATION
Required
Not Required
Received
CATEGORY:
20 Individual Home Care Service Provider
REVIEWED BY: __________________________________________________________________________
(NAME & TITLE)
(DATE)
ISSUE ANNUAL REGISTRATION:
YES _____
NO _____
REGISTRATION DATES:
FROM ___________
TO ___________
NOTES:
COMMENTS ON CERTIFICATE:
INDIVIDUAL HOME CARE SERVICE PROVIDER APPLICATION
6/8/2016
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