Get Nh Department Of Health & Human Services (dhhs) - Dhhs Nh

This guide provides clear, step-by-step instructions for completing the NH Department Of Health & Human Services (DHHS) form online. Users can navigate the form efficiently to ensure all necessary information is accurately submitted.

Follow the steps to successfully complete and submit the DHHS form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the full legal name of the individual. Ensure the name matches the official documents to avoid any discrepancies.
3. Next, provide the date of birth in the format MM/DD/YYYY. This is important for identification and records.
4. Complete the current address section by entering the street, city, state, and zip code. Double-check for accuracy to prevent issues in communication.
5. Fill in the telephone number fields for home, work, and cell. Provide at least one contact number for further correspondence if needed.
6. Authorize a Health Care Provider to disclose the protected health information. Clearly write the name of the Health Care Provider in the designated field.
7. Specify that the information is to be released to the NH Department of Health & Human Services - XEROX, with the correct mailing address.
8. Disclose the specific information required by checking the appropriate boxes for the dates of service and types of records needed.
9. Indicate the purpose of disclosure, which is for disability determination for NH Medicaid (NH Title XIX).
10. Read the statements regarding sensitive information thoroughly. Initial next to any statements that are applicable to you.
11. Complete the authorization section by signing the document, including the authority of the representative if applicable. Make sure a witness signature is also provided if required.
12. Finally, ensure any necessary supporting documentation for the representative’s authority is attached. Review all entries before submission.
13. After completing the form, save the changes, and you may opt to download, print, or share the form as needed.

Start filling out the DHHS form online today to ensure a smooth application process.