Provider Tools and Forms

Please select from the forms below. Files are in either Microsoft Word or PDF format.

 False Claim Prevention/Whistleblowers Policy

Behavior and Intervention

• Procedure - Review and Approval of Behavioral Interventions
• HRC - Behavior Plan/Protocol Approval Request
• Regional Standards for Implementing Programs to Address Behavioral Challenges

 

Certification Forms

• Application for Certification
• NH Bureau of Developmental Services Waiver Request
• Certification Residence Developmental Disabilities and Acquired Brain Disorder Certification Tool for 1-3 Person Homes
• Community Participation Annual Administrative Review Certification Tool
• Community Participation Services Certification Tool
• Day Services Packet for Certification
• DS-ABD Residential Information Packet for Certification
• Emergency Certification for Community Residence - 3 or Fewer Beds
• Checklist for Emergency Certification Application
• Request for Waiver to He-M 1201.06 (a) (3) (l) (11)
• Fire Safety Assessment
• Fire Drill Form
• Program Closure Notice

 

File a Complaint

• How to File a Complaint
• Complaint Investigation Response to Recommendations

 

Medication Administration

• Request for Waiver to He-M 1201
• Form 1201-A:  Six Month Nurse Trainer Report to NH Bureau of Developmental Services Medication Committee (For Programs with Reportable Errors)
• Form 1201-A Short:  Six Month Nurse Trainer Report to NH Bureau of Developmental Services Medication Committee (For Programs with Reportable Errors)
• Form 1201-B:  Six Month Provider Agency Report to NH Bureau of Developmental Services Medication Committee
• Form 1201-A Short Instructions
• Bureau of Developmental Services: He-M 1201
• 1201-B Instructions
• NH Bureau of Developmental Services Annual Health Screening Recommendations (Adult Preventative Care Recommendations)
• Medication Occurrence Report
• Epinephrine auto-injector Waiver Form April 2014

 

Misc Forms

• Mortality Notification
• Bureau of Developmental Services Budget Template - Frequently Asked Questions
• Community Bridges Travel Reimbursement Form
• HRST Monthly Data Tracker
• NH Family Ties Advisor Program

 

Partnerships

• 521 – Day & Residential Attendance Log
• Budget Reduction Policy
• Crisis Attendance Log
• Crisis Funding Request
• CSS Services Attendance Log
• Day Services Attendance Log
• Personally Directed Medicaid Services (PDMS) Budgets
• PDMS Budget Template
• Residential Services Attendance Log
• SEP Services Attendance Log
• Traditional Adult Medicaid Budgets
• Traditional Budget Template

 

Respite

• Electronic Respite Voucher
• Early Supports and Services - Respite Guide for Families
• Individual & Family Support Services - Respite Guide for Families

 

Rights Health Safety

• Client Rights Brochure
• Health History Information
• Incident Report Form
• Incident Restraint Form
• Incident Report Policy
• Legal Rights Brochure
• Nursing/Medical Intervention Report
• Seizure Report