NH Home and Community Based Services Waiver Provider Listing
If you would like your agency added to the CSNI contact list as open to referrals, or if you already provide services, please complete all fields on the form below. Even if there is only one contact for all areas, duplication is okay. CSNI will send this form quarterly to all providers listed by BDS as having a Medicaid ID and willing to provide HCBS Waiver Services in NH.
Agency Name
*
If your agency has multiple contacts for different departments within your agency, please complete this form once for each department, even if there is some level of duplication. For example, "ABC Agency - Service Coordination" would be one completion, "ABC Agency - Residential" would be another, etc.
What waiver services is your agency currently accepting referrals for? Select all that apply. Must align with services as described in NH He-M 517.
Waiver Service Types
Rows
Certified Residential - Enhanced Family Care
Certified Residential - Staffed Residence
Community Participation Services (Day Services)
Service Coordination
Supported Employment Services
Personal Care Services
Respite Care Services
Environmental Accessibility Modifications
Crisis Response Services
Community Support Services
Assistive Technology Support Services
Specialty Services
Check only if you are currently accepting referrals
Agency Contact Name for referrals
*
First Name
Last Name
Agency Contact Email Address for referrals
*
example@example.com
Agency Contact Name for Service Coordinators
*
First Name
Last Name
Agency Contact Email Address for Service Coordinators
*
example@example.com
Agency Leadership Contact Name
*
First Name
Last Name
Agency Leadership Contact Email Address
*
example@example.com
Company Website (URL)
*
Submit
Should be Empty: