SR 12-26 Dated 08/12

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases revisions to the Disability Determination Unit’s (DDU) Form 900, Authorization for Release of Protected Health Information, and its associated instructions. Revisions to this form, but primarily the instructions to the form, incorporate improved processes for sharing information between the Division of Family Assistance (DFA) and DDU due to the Electronic Document Imaging management process, and resulted in the removal of the no-carbon-required (NCR) printing of this form.

DESCRIPTION OF REVISIONS MADE TO FORMS

DDU Form 900, Authorization for Release of Protected Health Information, is used to obtain written permission for the release of confidential health information so that the DDU is able to make medical disability determinations on behalf of applicants or recipients of cash and/or medical assistance for the following programs:

·   Aid to the Needy Blind (ANB);

·   Aid to the Permanently and Totally Disabled (APTD);

·   Medicaid for Employed Adults with Disabilities (MEAD); and

·   Children with Severe Disabilities (CSD) and Home Care for Children with Severe Disabilities (HC-CSD).

Revisions to this form, mainly the instructions to the form, were primarily to remove the 3-part NCR printing of this form. Due to Electronic Document Imaging, NCRs are no longer required. Once the non-NCR version of DDU Form 900 is in use, DHHS staff will scan the completed form and then provide the original in the 940 packet sent to the DDU.

The form and its instructions were additionally revised to:

·   Remove the fill-in field associated with the expiration date of the authorization to simplify the completion of the form. Previously, the individual completing the form was notified in this section that if no date was specified in the field, the authorization would expire 12-months from the date the form was signed. To streamline the completion of the form, the fill-in field was removed, leaving the default expiration time period text. Text will now simply indicate that the authorization expires 12 months from the date the form is signed;

·   Request the client’s initials next to the authorization to release genetic testing records; and

·   Replace references to the Division of Community Based Care Services with Disability Determination Unit (DDU).

All workers should continue to use the old NCR versions of DDU Form 900 until the supply is exhausted. The new paper version of DDU Form 900 will be available for use when the current supply is depleted. Reorder using the current forms ordering system. The form is also available electronically on the DHHS website and internally, for Department staff only, on the Lotus Notes Family Services Database.

POLICY MANUAL REVISIONS

Revised Adult Assistance Manual Topics

PART 207  AID TO THE NEEDY BLIND

Section 207.01  Verification: ANB

Section 209.01  Verification: APTD

Section 210.01  MEAD Medical Criteria

Revised Family Assistance Manual Topics

PART 163  TERMINATION OF ASSISTANCE

Section 223.03  Required Verification

Section 223.05  Three-Month Temporary Adjustment Period

Section 225.03  Required Verification

Section 225.05  Three-Month Temporary Adjustment Period

IMPLEMENTATION

District Offices and DDU staff are to continue to use the old NCR versions of DDU Form 900 until their supply is exhausted. The new paper version will be available for use when the current supply is depleted and can be reordered using the Quarterly Forms Order (QFO), per usual process. The form is also available electronically on the DHHS website and internally, for Department staff only, on the Lotus Notes Family Services Database.

CLIENT NOTIFICATION

No special client notification is planned or needed.

TRAINING

No special training is planned.

FORMS MANUAL POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed or deleted after its contents have been noted and the SR has been posted to the On-line manual.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR, and revised On-Line Manuals, will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at www.dhhs.nh.gov/DFA/publications.htm, effective August 27, 2012. Additionally, this SR will be distributed under separate cover to all internal hard copy holders of the Forms, Adult Assistance, and Family Assistance Manuals.

DFA/JBV:s