Get Nhhan Form

Filling out the Nhhan Form online can be a straightforward process when guided correctly. This document is essential for applying for financial assistance in healthcare and requires accurate information to ensure eligibility.

Follow the steps to complete the Nhhan Form online.

1. Click the ‘Get Form’ button to access the Nhhan Form and open it in the online editor.
2. Begin by entering the patient's information. Fill in the last name, first name, middle initial, street address, social security number, city, mailing address, state, date of birth, and zip code. Be sure to indicate the patient's phone number preference by checking either the home or work phone option and select the marital status from the given choices.
3. Provide details about the person responsible for paying the bill. This includes their last name, first name, middle initial, relationship to the patient, and contact details including their address if different from the patient's, home phone number, work phone number, name of the insurance company, and the effective date.
4. List all individuals living in the household, including the applicant. For each person, record their name, social security number, relationship to the patient, and date of birth. If more space is needed, use an additional sheet of paper.
5. Indicate if the application is for future or past services and provide the applicable dates of service.
6. Answer whether anyone in the household has applied for NH Healthy Kids or Medicaid, including the date of application and its status.
7. Specify if anyone in the household is pregnant and provide the name and reason if applicable.
8. Indicate whether any member of the household has served in the military.
9. Specify if there are any recent claims filed for workers' compensation or motor vehicle accidents.
10. Indicate if anyone in the household is eligible for Social Security benefits, including the date and name of the individual.
11. Provide information on health insurance coverage for anyone in the household.
12. Fill out the household information section, noting each member's monthly income, including from employment, self-employment, investments, and any other sources. Be sure to specify any checking and savings account balances, retirement accounts, and the value of vehicles.
13. Document household expenses, including rent or mortgage payments, property taxes, and other relevant financial commitments.
14. Read and acknowledge the assignment of rights section carefully. Sign and date the application, ensuring all information provided is true and accurate.
15. Once all sections are filled out, review the form for completeness and accuracy. Save your changes, and you may choose to download, print, or share the form.

Begin filling out the Nhhan Form online today to secure the financial assistance you may need.