SUMMARY

This Supervisory Release (SR) releases revisions to DDU Form 177 Non-Medical Evaluation of Disability, DDU Form 177b What is APTD, DDU Form 900 Authorization for Release of Protected Health and DDU Form 968 CSD Family Information Report.

 

   POLICY

No policy is being changed by the release of this SR.

 

   NEW HEIGHTS & NH EASY SYSTEMS PROCEDURES

Revised DDU Form 177 and DDU Form 968 will be batchable in New HEIGHTS in December.

NH EASY will have the revised versions of DDU Forms 177, 900 and 968 available in December 2022. in the “Forms”section of NH EASY.

In addition, the following DDU Forms will be added to the NH EASY “Forms” repository: 177(Sp), 177b, 177b(Sp), 900(Sp) and 968(Sp).

 

   DESCRIPTION OF REVISIONS MADE TO FORMS

The following changes have been made to DDU Forms and their Spanish translations:

·   DDU Form 177 Non-Medical Evaluation of Disability and its Spanish translation DDU Form 177(Sp):

-    A cover sheet has been added, making this form 9 pages;

- Social Security Number has been moved to the top “Personal Information” section;

-  An email address spot has been added;

- Questions related to applying for SSI and SSDI have been separated to document the status   of each benefit separately;

- The “Ability To Work” section has been revised to allow clients to list any of their conditions;

-  “Employment History” “Education” and “Vocational Rehabilitation” sections have been re- arranged and edited for clients ease of completion;

- A section has been added to “Employment History” for clients to list any accommodations they may have or had received in any of their employments;

- There are no longer separate pages for “Provider” information vs “Facility” information; the   information for both pages have been merged; and

-    The “Insurance and Injury Liability” section has been removed.

·   DDU Form 177b What is APTD and its Spanish translation DDU Form 177b(Sp):

-    A header and footer have been added;

-    Minor edits to grammar have been made.

·   DDU Form 900 Authorization for Release of Protected Health Information and its Spanish translation DDU Form 900(Sp):

-   The disclosure of Complete Records option has been removed along with all of the types of medical records and has been replaced with an Authorization header which includes the statement that the individual understands that they authorize all PHI on released medical records

-  Authorization header also now includes yes check boxes to allow medical records that include records regarding psychological, psychiatric, gene, Sickle Cell Anemia, communicable/non- communicable diseases, SUD, and HIV/AIDS, which was previously under Purpose of Disclosure header and required initials.

-  Purpose of Disclosure header is now over the statement regarding the individual understanding that medical records and information is necessary for their eligibility  determination

- A footer with the message “A photocopy of this authorization will be considered as effective as the original” has been added;

-    Federal and state provisions regarding the disclosure of information are now indicated;

-    Added Durable Power of Attorney (DPOA) as an authority of representative option;

- A witness signature is no longer required.

-    A note was added advising that copies for legal authority of representation must be attached.

·   DDU Form 968 CSD Family Information Report and its Spanish translation DDU Form 968(Sp):

- Adding Bureau of Family Assistance to the header;

- Updating the form name from DDU Form 968 CSD Family Information Report to DDU Form 968 HC-CSD Family Information Report;

- Minor edits to grammar and formatting.

   IMPLEMENTATION

Recycle all previous versions of DDU Forms 177, 177b, 900, 968 and the Spanish translated versions of DDU Forms 177, 177b, 900 and 968.A Certificate of Destruction has been included below.

Place an order through the DHHS Warehouse/Logistics via the District Office’s Quarterly Forms Order (QFO) when a supply of the new versions or the Spanish translated versions are needed.

DDU Forms 177, 177b, 900 and 968 as well as their Spanish translated versions will also be available electronically on DHHS Website at http://www.dhhs.nh.gov/forms-documents and NH Easy Gateway to Services at https://nheasy.nh.gov/#/forms/.

DDU forms 177, 177(Sp) 177b, 177b(Sp), 900, 900(Sp) 968 and 968(Sp) will also available internally, for Department staff only, on the N:\ drive upon release of this SR.

   CLIENT NOTIFICATION

No client notification is needed.

 

   FORMS MANUAL POSTING INSTRUCTIONS

 

Remove and Destroy	Insert/Replace
DDU Form 177, Non-Medical Evaluation of Disability, 06/07 Rev 7/19 4 double sided sheets DDU Form 177 (Spanish), Non-Medical Evaluation of Disability, No SR # listed 4 double sided sheets	DDU Form 177, Non-Medical Evaluation of Disability, BFA SR 22-31 12/22 4 double sided sheets & 1 single sided sheet DDU Form 177(Sp), Non-Medical Evaluation of Disability, BFA SR 22-31 12/22 4 double sided sheets & 1 single sided sheet
DDU Form 177b, What is APTD, SR 02-06 Rev 07/04 1 double sided sheet DDU Form 177b(Sp), What is APTD, 08/01 1 double sided sheet DDU Form 900, Authorization for Release of Protected Health Information, SR 12-26 rev3 5/15 1 double sided sheet DDU Form 900, Authorization for Release of Protected Health Information, “Spanish version” 1 double sided sheet	DDU Form 177b, What is APTD, BFA SR 22-31 12/22 1 double sided sheet DDU Form 177b(Sp), What is APTD, BFA SR 22-31 12/22 1 double sided sheet DDU Form 900, Authorization for Release of Protected Health Information, SR 22-31 rev 12/22 1 double sided sheet DDU Form 900(Sp), Authorization for Release of Protected Health Information, BFA SR 22-31 12/22 1 single sided sheet
DDU Form 968, CSD-Family Information Report, SR 12-26 Rev 10/19 4 double sided sheets & 1 single sided sheet DDU Form 968, CSD-Family Information Report, 11-12 “Spanish version” 4 double sided sheets	DDU Form 968, HC-CSD Family Information Report, BFA SR 22-31 12/22 4 double sided sheets DDU Form 968(Sp), HC-CSD Family Information Report, BFA SR 22-31 12/22 4 double sided sheets

 

DISPOSITION

This SR may be destroyed or deleted after its contents have been noted and the revised manual topics released by this SR have been posted to the On-line Manuals.

 

   DISTRIBUTION

This SR will be distributed according to the electronic distribution list for BFA 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 https://www.dhhs.nh.gov/sr_htm/sr.htm.

 

BFA/DMS:rs