Application Package for

Application Package for Licensing a Change in Ownership of a Residential Care or Health Facility
Owner:	Bureau of Health Facilities Administration
Effective Date:	07/01/2009
Step 1. An appropriate application for the type of facility requested needs to be filled out and submitted with appropriate fees to: NH DHHS, Office of Program Support Bureau of Health Facilities Administration 129 Pleasant Street Concord, NH 03301-3857 Step 2. Centers for Medicare & Medicaid Services (CMS) Forms Certified health facilities also need to complete the: CMS 855 A form Completed CMS 855A forms need to be sent to your fiscal intermediary for processing.