109 APPLICATION PROCESS SR 11-40, 10/11 (AAM-A)

To complete the application process, the applicant must do all of the following:

• complete an application;

• participate in an eligibility interview, if required by the program of assistance requested; and

• provide all required verification within timeframes.

Individuals have the right to:

• apply for assistance;

• file an application on the same day the District Office has been contacted; and

• have an eligibility decision made on their application for assistance.

Advise individuals that they may file the application before an interview is conducted.

Individuals can apply for assistance in 3 ways:

• Individuals can apply for assistance by visiting the following website and completing an application online: https://nheasy.nh.gov;

• Individuals can print out an application from http://www.dhhs.nh.gov/dfa/apply.htm and mail the completed application to the District Office; or

• Individuals can contact a District Office and request an application per the instructions below.

Individuals may also apply for assistance at hospitals by completing and submitting DFA Form 800, Application for Assistance.

Requesting an Application from a District Office

An individual may request an application by contacting any District Office.

• DFA Form 800, Application for Assistance, is provided to any individual requesting an application.

• DFA Form 800Q, Assisted Application For Help With Medicare Costs Through the Medicare Savings Program, is a mail-in application used by New Hampshire Housing Authority (NHHA) and ServiceLink to help NHHA residents and ServiceLink-assisted individuals apply for the Qualified Medicare Beneficiary (QMB), Special Low Income Medicare Beneficiary (SLMB), Special Low Income Medicare Beneficiary at 135% of federal poverty income guidelines (SLMB135), and Qualified Working and Disabled Individual (QDWI) programs.

If the individual contacts the District Office by telephone, fax, or mail, direct the individual to the NH EASY website so that the individual can immediately complete the online application, or notify the individual of the availability of the application on the Department’s website, where DFA Form 800 can be printed off immediately for the individual’s use. If the individual does not have access to a computer or the Internet, mail DFA Form 800 to the individual on the same day the request is received.

Completing an Application

A completed application for the adult categories of assistance must, at minimum, contain the applicant’s name, address, signature, and type of assistance requested.

Application Filing Date

The official Filing Date for applications is the date when the application is completed as described above and received by the District Office. If a paper application is received, this date is stamped onto the official application, and entered onto the "coversheet" of DFA Form 800 before the coversheet is returned to the applicant for reference. Also see Section 109.01, Filing an Application.

Eligibility Interview

Most applicants, including applicants for nursing facility care, are required to also participate in a detailed interactive Application Entry (AE) eligibility interview with a Family Services Specialist (FSS). See PART 121, INTERVIEWS.

Required Verification

All applicants must provide verification of:

• eligibility factors and circumstances;

• information related to benefit allotment amount; and

• information the individual provided on the application or to the FSS during the interview. See PART 123, PENDING INFORMATION.