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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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