BEAS 3865 12/2018 STATE OF NEW HAMPSHIRE Department of Health and Human Services Division of Long Term Supports and Services (DLTSS) Bureau of Elderly and Adult Services (BEAS) Choices for Independence (CFI) Program Waiver Request
BEAS 3865 is completed when requesting a waiver of a specific procedure contained in He-E 801, the administrative rule on the CFI Program. Such requests are reviewed and approved in accordance with He-E 801.34, “Waivers”. Submit completed requests to: Administrator, Long Term Care Medical Eligibility Unit, Bureau of Elderly and Adult Services using one of the following: EMAIL: CFIWaiver@dhhs.nh.gov FAX#: (603) 271-7985 U.S. MAIL: 105 Pleasant St. Main Building, Concord NH 03301. BEAS PHONE #: (603) 271-9203 *Criminal record checks must be current, within one year of the waiver request. *Only waiver requests completed in full will be processed. *Additional pages may be attached as necessary
Date of Request: Who is making the Request: CFI Applicant/Participant CFI Case Manager Provider Agency Guardian
Indicate: Initial Renewal	If Renewal, indicate Waiver Number: Expiration Date:
Provider Agency (if applicable)	Participant Name (if applicable)	Staff Name (if applicable)
Waiver for Residence: Other:	For Licensed/Certified Residence ONLY: Provide name and address as it appears on the Certificate:	For Licensed/Certified Residence ONLY: Certificate #: Expiration Date:
Indicate the specific standard from which you request a waiver: He-E Quote the specific language you seek to waive:
Provide a full explanation of why a waiver to this standard is sought:

Describe the proposed alternative to satisfy regulatory intent:

SIGNATURES

CFI Applicant/Participant or Guardian: ____________________________________________________________________

Date:

Case Manager: ________________________________________________________________________________________

Date:

Provider Agency Director or Designee: ____________________________________________________________________

Date:

FOR NH DEPARTMENT OF HEALTH AND HUMAN SERVICES USE ONLY:

The waiver request is:

Approved (Waivers that are approved are effective as of the date of the signature below.)

Not Approved (State the reason):

Signature of BEAS Bureau Chief or Designee: ______________________________________________________________

Date of Signature:

BEAS 3866, the notification on the waiver request, is sent to the requester and to all others who signed the BEAS 3865 waiver request form.