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Outpatient basis (see full text in RSA 151-C:13 I, (a)). Section RSA 151-C:5 Cost does not exceed threshold (a) Capital Expenditures (RSA 151-C:5, II (a) or (f)). $_______________________________ (go to Section IV) (b) Equipment (RSA 151-C:5, II (d)). $______________________________ (go to Section IV) This is a dispensary or first-aid station within a business or industrial establishment that does not provide inpatient or resident beds (RSA 151-C:13, I (b)). Please indicate if equipment is: .

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