CHAPTER Saf-C 7800 FIREFIGHTER MEDICAL EXAMINATION
REIMBURSEMENT
PART Saf-C 7801 PURPOSE AND SCOPE
Saf-C 7801.01 Purpose. The purpose of this chapter is to establish procedures
for reimbursement for medical examination for regular firefighters under RSA
281-A:17, II (d).
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Saf-C 7801.02 Applicability. This chapter shall apply to regular
firefighters and municipal fire departments who pay for medical examinations
conducted on or after July 17, 2019.
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PART Saf-C
7802 DEFINITIONS
Saf-C 7802.01 “Applicant” means a regular
firefighter or municipal fire department on behalf of a regular firefighter.
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Saf-C 7802.02 “Department” means the New Hampshire
department of safety.
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Saf-C 7802.03 “Division” means the New Hampshire
department of safety, division of fire standards and training and emergency
medical services.
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Saf-C 7802.04 “Medical examination” means a medical
examination outlined by the National Fire Protection Association (NFPA) Standard on
Comprehensive Occupational Medical Program for Fire Departments 1582.
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Saf-C 7802.05 “Occupational healthcare provider”
means a health care provider that specializes in medical examinations outlined
in NFPA Standard on Comprehensive Occupational Medical Program for Fire
Departments 1582.
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Saf-C 7802.06 “Regular firefighter” means a
full-time active firefighter, whose employment in New Hampshire began prior to
January 1, 1997.
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PART Saf-C 7803 REIMBURSEMENT PROCESS
Saf-C 7803.01 Reimbursement Process
(a) The department
shall reimburse applicants for the costs incurred for medical examinations
subject to the following requirements, conditions, and limitations:
(1) Applicants shall submit all documentation required under Saf-C
7803.03;
(2) The medical examination shall be conducted by
an occupational healthcare provider;
(3) Reimbursement shall be made for the cost
actually incurred for the medical examination by the applicant;
(4) No costs outside of the medical examination
shall be eligible for reimbursement
under this chapter;
and
(5) The limitations on reimbursement provided for
under RSA 281-A:17, II, (d) shall not be increased by the proceeds from any
insurance policy procured by any applicant.
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Saf-C 7803.02 Vendor Registration
(a) The applicant seeking reimbursement
shall register as a vendor with the State of New Hampshire by completing the
State of New Hampshire Alternate W-9 Form.
(b) Each applicant shall furnish the
following information on the State of New Hampshire Alternate W-9 Form:
(1) Applicant’s name or legal business name;
(2) Applicant’s mailing address;
(3) Applicant’s business mailing address, if applicable;
(4) Applicant’s Taxpayer Identification;
(5) Applicant’s principal activity;
(6) Applicant’s designation;
(7) Applicant’s name and title;
(8) Applicant’s telephone number, cell phone
number and fax number, if applicable;
(9) Applicant’s signature, and date;
(10) Applicant’s website, if applicable, and
primary email address.
(c) The State of New
Hampshire Alternate W-9 Form and Vendor Application may be found at the
following link: https://das.nh.gov/purchasing/vendorregistration/(S(fyvi0k55xi2hx0i0ws1fgwbc))/welcome.aspx.
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Saf-C 7803.03 Application Requirements
(a) The applicant shall complete and submit the
“Application for Medical Evaluation Reimbursement” form, dated 12/2020.
(b) The applicant shall include the following documentation
with the “Application for Medical Evaluation Reimbursement” form:
(1) A completed and signed copy of the
“Occupational Health Provider Verification” form, dated 12/2020; and
(2) A legible itemized paid receipt from the occupational healthcare provider.
(c) The above documentation
shall be submitted to the division within 60 days of the date of the medical
examination.
(d) If the medical
examination occurred after July 17, 2019 but prior to
the effective date of this chapter, the above documentation shall be submitted
no later than 60 days after the effective date of this chapter.
(e) Notwithstanding
any rule to the contrary, applicants shall apply for reimbursement of medical
examinations during the state fiscal year with termination of reimbursement for
eligible costs at the end of the fiscal year on June 30.
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APPENDIX A
|
Rule Number |
Statute Implemented |
|
Saf-C 7801.01 – 7801.02 |
RSA 281-A:17, II (d); RSA 541-A:7 |
|
Saf-C 7802.01 – 7802.06 |
RSA 281-A:17, II (d); RSA 541-A:7 |
|
Saf-C 7803.01 – 7803.03 |
RSA 281-A:17, II (d); RSA 541-A:7 |
APPENDIX B
|
Rule |
Title |
How to Obtain: |
|
Saf-C 7802.04 Saf-C 7802.05 |
National Fire Protection Association, (NFPA) 1582,
Standard on Comprehensive Occupational Medical Program for Fire Departments |
National Fire Protection Association 1 Batterymarch Park Tel: 800.344-3555 Fax:
800.593-NFPA On-line
access. Free of charge Hard Copy Cost: $67.50 |