SR 24-24 Dated 09/24

STATE OF NEW HAMPSHIRE

DEPARTMENT OF HEALTH & HUMAN SERVICES - Bureau of family assistance (bfa)

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This Supervisory Release (SR) releases revisions to DDU form 177 Non-Medical Evaluation of Disability.

This SR also releases the official name change to DDU form 900 from Authorization for Release of Protected Health Information to Authorization for Release of Medical Records and Information.

NEW HEIGHTS & NH EASY SYSTEMS PROCEDURES

Revised DDU Form 177 will be batchable in New HEIGHTS  and available on NH EASY. It will also be updated in the forms drop-down on the Disability Request screen in HEIGHTS 10/1/2024.

DDU form 900 will have updated title when batching in New HEIGHTS. The title and the description have also been updated on NH EASY. It will also be updated in the forms drop down on the Disability Request screen in HEIGHTS 10/1/2024.

F3 pages ‘SSP-APTD or OAA Interview reference’ and ‘SSP-APTD Forms and Pamphlets Reference’ have been updated.

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):

- Updated the cover page to include needing a  DDU 900 form for Social Security Administration (SSA)

-   Changed Form 900 title to Authorization for Release of Medical Records and Information

-   Added lien exception under “Please note”

-   “Employment History” section has been changed to now require 5 years of past work history

-   Minor edits to grammar have been made

·         BFA Form 900(i) Instruction sheet for, DDU form 900, Authorization for Release of Medical Records and Information

-   Changed title for form 900 to Authorization for Release of Medical Records and Information

- “Instructions" section #5 to include needing a 900 form for Social Security Administration

POLICY MANUAL REVISIONS

Adult Assistance Manual Topics

209.01      Verification: APTD

Medical Assistance Manual Topics

209.01      Verification: APTD

211.01      MEAD Medical Criteria

229.01      Required Verification: CSD

231.03      Required Verification: HC-CSD

IMPLEMENTATION

This policy is effective upon release of this SR. Recycle all previous versions of DDU Form 177 and the Spanish translated version as well as DDU form 900(i).

Place an order through 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 form 177 as well as the Spanish translated version will be available electronically on the DHHS Website http://www.dhhs.nh.gov/forms-documents and NH EASY Gateway to services at https://nheasy.nh.gov/#/forms.

DDU form 177,177(SP), and 900(i) will be available internally for Department staff only, on the N:\drive upon release of this SR.

CLIENT NOTIFICATION

 No special client notification is planned or needed.

TRAINING

No special training is planned or needed.

FORMS INSTRUCTIONS

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 Online Manuals.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for BFA policy releases. This SR, and revised Online Manuals, will be available for agency staff in the Online Manual Library, and for public access on the Internet at https://www.dhhs.nh.gov/sr_htm/sr.htm, effective October 1, 2024.

BFA/DMS:kb