Ive (AR) to help you with some or all of the steps needed to apply for or get benefits. These benefits include: cash, medical, Food Stamps, and/or Child Care assistance. An AR is a friend, family member, or other person who has a concern for your well-being. An AR is a person you choose. We will not choose one for you. The person you choose must agree to help you. An agency cannot act as an AR, but a person working at an agency can. An AR must be an individual person. An AR may go to eligibility.

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How to fill out the NH DFA Form 778 online

This guide provides clear instructions for completing the NH DFA Form 778, which is essential for designating an authorized representative. By following the steps outlined here, you can efficiently fill out the form online to ensure that your selected representative can assist you with your benefits.

Follow the steps to complete the NH DFA Form 778 online.

  1. Click the ‘Get Form’ button to obtain the NH DFA Form 778 and open it in your preferred online editor.
  2. Begin by reading the introduction section carefully. This will give you an overview of the purpose of the form, which is to select someone to assist you with your benefits application.
  3. In the Authorized Representative Duties section, indicate which activities you want your representative to perform by checking the appropriate boxes. Review the list, which includes options like filling out forms and attending eligibility interviews.
  4. In the Client’s Signature section, read the statements thoroughly. You must certify that you understand your responsibilities and agree to the terms. Enter your printed name, date of birth, and provide your signature.
  5. Complete the Authorized Representative Information section. Clearly print your representative’s first name, middle initial, last name, and their contact information, including address and phone numbers.
  6. Ask your authorized representative to sign the form in the designated area, confirming that they understand the responsibilities outlined in the form.
  7. Finally, review the entire form for accuracy. Once you are satisfied with the information provided, you can save the changes, download your completed form, print it, or share it as needed.

Complete your NH DFA Form 778 online today to ensure your benefits are managed effectively.

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What is an authorized representative?

Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person.

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.

Plan Options Household Size100%150% 2 $16,240 $24,360 3 $20,420 $30,630 4 $24,600 $36,900 5 $28,780 $43,1705 more rows

The asset limits for the Medically Needy Pathway are $2,500 for an individual and $4,000 for a couple. 2) Asset Spend Down – Seniors who have assets over Medicaid's limit can “spend down” countable assets on non-countable ones to become asset-eligible.

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