Get Form 177

Filling out the Form 177 online is an essential step in the process of applying for disability determination through Medicaid services. This guide provides you with clear and supportive instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the Form 177 online successfully.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin with the personal information section. Fill out your name, date of birth, and any other names used in medical records. Indicate whether you are currently receiving NH Medicaid and provide your household residence and mailing addresses.
3. Complete your contact information by entering your daytime telephone number and any preferred language if you cannot speak or understand English.
4. In the ability to work section, describe any illnesses, injuries, or conditions that limit your work capacity. Next, specify if these conditions cause you pain and select any relevant impacts they may have on your job duties.
5. Next, indicate your current employment status and provide details on why you may have stopped working, including the date of cessation.
6. Proceed to the vocational rehabilitation section. Indicate if you are currently receiving vocational rehabilitation services and provide any previous service details.
7. Fill out the education section, indicating the highest grade completed and any special job training you may have undergone.
8. List all jobs held in the past 15 years, along with the respective dates, job titles, and key responsibilities. Take note of jobs where you encountered challenges due to your disabling conditions.
9. Answer the mental health information questions honestly, detailing any emotional or mental health problems and related services you may be receiving.
10. Provide information regarding any other medical insurance you may have and specify if your disability resulted from an accident, including details about the incident.
11. List all medical professionals who have your medical records and provide relevant details like names, addresses, and reasons for visits.
12. Indicate any medications you are currently taking along with information about your doctors. Include any upcoming medical tests you are scheduled for.
13. Finally, ensure you acknowledge the certification statement and sign the form. If someone assisted you in filling out the document, include their signature and relationship to you.
14. After completing the form, save your changes, download it, or print it out for your records. You may also share it with others if needed.

Take the first step towards your disability determination by completing the Form 177 online today!