Get Form 720 Dhhs

Filling out the Form 720 Dhhs is an essential step in determining incapacity status for individuals seeking financial assistance. This guide provides clear and supportive instructions to complete the form online efficiently.

Follow the steps to fill out the Form 720 Dhhs accurately.

1. Press the ‘Get Form’ button to access the form and open it for completion.
2. Fill in your personal details at the top of the form, including your name, case number, and the application date. Ensure that all information is accurate and current.
3. In the authorization section, read the details carefully. You are granting permission for specific information to be used or disclosed, so ensure you understand what you are authorizing.
4. Indicate the specific persons or organizations that are authorized to use and/or disclose your health information. It is typically the Health Care Provider and the New Hampshire DHHS.
5. In the section detailing the specific information to be disclosed, describe your capacities, environment, activities, and any limitations that affect your ability to care for your children for at least 30 continuous days.
6. Review the purpose for which the information will be used. It is primarily to determine eligibility for Financial Assistance to Needy Families.
7. At the bottom of the form, sign and date it to confirm your understanding and authorization. Clearly print your name as it should appear.
8. Ensure the reverse side of the form is completed by a healthcare provider who certifies your incapacity. This section must be filled out by a physician, PA, APRN, or psychologist.
9. Once the form is fully completed, review it for accuracy, then choose to save changes, download, print, or share the form as needed.

Complete the Form 720 Dhhs online today to ensure timely processing of your application.