167.01 Definition of a Complete DFA Form 890 (MAM)

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DFA Form 890, Quarterly Extended Medical Assistance Report, is complete if all of the following are done:

• all questions are answered;

• the individual signs and dates the form; and

• required verification is provided to substantiate the information on the form.

References: He-W 606.98; He-W 882.05; RSA 167:82, VI; 42 USC 1396r-6(b); 42 USC 1396u-1(c)(2)