Standard Disclosure Form - New Hampshire Department of Health 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering the facility name at the top of the form. This identifies the location providing services.
  3. Fill in the base rate for services, specifying whether it is a monthly or weekly charge. Include any deposit or advance payment details as applicable.
  4. Check all included services under 'Services Included in the Base Rate'. Specify daily meal options and housekeeping frequency.
  5. Indicate personal assistance services provided according to the resident’s care plan, such as bathing and medication administration.
  6. Complete the section on personal living unit amenities, marking those available in common areas with an 'X'.
  7. Detail staff coverage hours and types of staff available, ensuring clarity on on-site and on-call hours.
  8. Review additional comments and ensure both prospective resident and facility staff sign and date the form before submission.

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