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Forms and Instructions - Nursing Facility Quality Assessment

To sort forms by "Form Number" or "Name/Description", click on that item in the table header.

  • The following forms are fillable PDF forms which can be opened, completed, and saved.
  • An alternative print version of most forms are available that have limited functionality but may be easier to open.
  • To achieve the best results, we recommend the latest version of both your web browser and Adobe Acrobat Reader.

You may also save the form as a PDF to your computer, complete the form, and then print and mail the form to the address listed.

To save a PDF form to your computer:

1. Right click on the title link of the form you want to save.
2. Select “Save Target As” or “Save Link As.”
3. Choose a location to save the document and click "Save."
4. Open the form using a PDF Reader that supports the ability to complete and save PDF forms. (Adobe's Acrobat Reader is free and is the most popular of these programs.)

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To request forms, please email forms@dra.nh.gov or call the Forms Line at (603) 230-5001. If you have a substantive question or need assistance completing a form, please contact Central Tax Services at (603) 230-5920.

Document Number
(fillable PDF)
Document Number
(print PDF)
Document Description
DP-156 (fillable)  pdf file DP-156 (print)  pdf file Nursing Facility Quality Assessment Return
See Form for Instructions
DP-156-ACH (fillable)  pdf file DP-156-ACH (print) pdf file Nursing Facility Assessment Authorization Agreement for Pre-Authorized Payments (ACH Debits)
See Form for Instructions
DP-156-PMT (fillable)  pdf file DP-156-PMT (print)  pdf file Nursing Facility Return Payment
See Form for Instructions
HHS Worksheet (fillable)  pdf file HHS Worksheet (print)  pdf file Nursing Facility Quality Assessment Calculation Worksheet
See Form for Instructions

Adobe Acrobat Reader Symbol Adobe Acrobat fillable format. You can download a free fillable PDF reader from Adobe.

Adobe Acrobat Reader Symbol Portable Document Format (.pdf). Visit nh.gov for a list of free .pdf readers for a variety of operating systems.


New Hampshire Department of Revenue Administration
Governor Hugh Gallen State Office Park
109 Pleasant Street (Medical & Surgical Building), Concord NH
(603) 230-5000  |  
TDD Access Relay NH: 1-800-735-2964  |  
fax: (603) 230-5945
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