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STATE OF NEW HAMPSHIRE DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAID SERVICES DISABILITY DETERMINATION UNIT DDU Form 177 06/07 PAGE 1 OF 8 NON MEDICAL EVALUATION OF DISABILITY Initial Review Family Services Specialist Application Date TDD Access Relay NH 1-800-735-2964 District Office PERSONAL INFORMATION Name Male Female Date of Birth List any other names that you may have used on your medical records such as maiden name previous married name.

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Questions? 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.

Service authorization requests for Medicaid Fee for Service recipients can be found on the MMIS online portal. All service authorizations should be submitted via secure email at ServiceAuthorizationFFS@dhhs.nh.gov.

Division of Medicaid Services. As Medicaid Director, Henry Lipman is the New Hampshire state lead for coordination with the U.S. Centers for Medicaid and Medicare Services.

Form 177: Non-Medical Evaluation of Disability: This form is used by the Disability Determination Unit to determine medical eligibility for the program you have applied for and must be filled out completely. Please answer all questions. If a question does not apply, please write N/A.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
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