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  • Dhhs Client Statement Form 65

Get Dhhs Client Statement Form 65

NH Department of Health Human Services DHHS Division of Family Assistance DFA DFA Form 65 11/01 Rev 3/2011 rev2 3/15 Client s Printed Name Date Client s Case Number CLIENT STATEMENT Shelter Statement Fraud Statement Voluntarily Withdrawing Application Voluntarily Terminating Assistance Initiate Change or Remove a Vendor Payee Change the Amount of a Lack of Adequate Child Care Loss of Employment Other Client s Statement Signature of Casehead Print.

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Contact the DHHS Customer Service Center toll-free at 1-844-ASK-DHHS (1-844-275-3447) (TDD Relay Access: 1-800-735-2964), Monday through Friday, 8:00 a.m. to 4:00 p.m. ET. Contact your local District Office.

If any changes are required to ERA enrollment information, the Provider will contact Provider Relations call center at 866-291-1674.

Call us at 1-866-769-3085 (TDD/TTY 1-855-742-0123).

If you have questions, please contact Provider Enrollment at (603) 223-4774 or (866) 291-1674, Monday through Friday, 8 am - 5 pm EST. If you would like to become a Non-Billing Provider for New Hampshire Medicaid, please complete the appropriate online application.

NH Medicaid (Medical Assistance) is a federal and state funded health care program that serves a wide range of individuals and families who meet certain eligibility requirements.

There are three New Hampshire Medicaid Health Plans to choose from: AmeriHealth Caritas New Hampshire. NH Healthy Families. WellSense Health Plan.

Providers without internet access should ask for alternate arrangements by calling the Medicaid Provider Call Center at (866) 291-1674 or (603) 223-4774.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232