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- United States Legal Forms
- New Hampshire Legal Forms
- New Hampshire Department of Health and Human Services
- New Hampshire Department of Health and Human Services - Division of Family Assistance
Documents
22
![DFA Formulario 778 "Declaracion Del Representante Autorizado (Ra)" - New Hampshire (Spanish)](https://data.templateroller.com/pdf_docs_html/1875/18753/1875376/dfa-formulario-778-declaracion-del-representante-autorizado-ra-new-hampshire-spanish.png "DFA Formulario 778 "Declaracion Del Representante Autorizado (Ra)" - New Hampshire (Spanish)")
![DFA Form 77U "It Takes a Village" - New Hampshire](https://data.templateroller.com/pdf_docs_html/2049/20494/2049421/dfa-form-77u-it-takes-a-village-new-hampshire.png "DFA Form 77U "It Takes a Village" - New Hampshire")
![DFA Formulario 77U "Se Necesita Un Pueblo" - New Hampshire (Spanish)](https://data.templateroller.com/pdf_docs_html/2049/20494/2049425/dfa-formulario-77u-se-necesita-un-pueblo-new-hampshire-spanish.png "DFA Formulario 77U "Se Necesita Un Pueblo" - New Hampshire (Spanish)")
![DFA Form 778 "Authorized Representative (Ar) Declaration" - New Hampshire](https://data.templateroller.com/pdf_docs_html/1875/18753/1875372/dfa-form-778-authorized-representative-ar-declaration-new-hampshire.png "DFA Form 778 "Authorized Representative (Ar) Declaration" - New Hampshire")
![DFA Form 474 "Attestation and Verification of Food Stamp (Fs) Household Disaster" - New Hampshire](https://data.templateroller.com/pdf_docs_html/1875/18753/1875394/dfa-form-474-attestation-and-verification-of-food-stamp-fs-household-disaster-new-hampshire.png "DFA Form 474 "Attestation and Verification of Food Stamp (Fs) Household Disaster" - New Hampshire")
![DFA Form 821 "Application for Medicaid Presumptive Eligibility (Pe)" - New Hampshire](https://data.templateroller.com/pdf_docs_html/1875/18753/1875391/dfa-form-821-application-for-medicaid-presumptive-eligibility-pe-new-hampshire.png "DFA Form 821 "Application for Medicaid Presumptive Eligibility (Pe)" - New Hampshire")
DFA Form 821 "Application for Medicaid Presumptive Eligibility (Pe)" - New Hampshire
Size: 403 KB
2 pages
![DFA Form 822 "Notice of Presumptive Eligibility (Pe)" - New Hampshire](https://data.templateroller.com/pdf_docs_html/1875/18753/1875393/dfa-form-822-notice-of-presumptive-eligibility-pe-new-hampshire.png "DFA Form 822 "Notice of Presumptive Eligibility (Pe)" - New Hampshire")
![DFA Formulario 474 "Atestacion Y Verificacion De Desastre Sufrido Por El Nucleo Familiar Que Recibe Cupones De Alimentos (Food Stamp, Fs)" - New Hampshire (Spanish)](https://data.templateroller.com/pdf_docs_html/1875/18753/1875387/dfa-formulario-474-atestacion-y-verificacion-de-desastre-sufrido-por-el-nucleo-familiar-que-recibe-cupones-de-alimentos-food-stamp-fs-new-hampshire-spanish.png "DFA Formulario 474 "Atestacion Y Verificacion De Desastre Sufrido Por El Nucleo Familiar Que Recibe Cupones De Alimentos (Food Stamp, Fs)" - New Hampshire (Spanish)")
![DFA Formulario 821 "Solicitud Para Elegibilidad Presunta (Pe) De Medicaid" - New Hampshire (Spanish)](https://data.templateroller.com/pdf_docs_html/1875/18753/1875392/dfa-formulario-821-solicitud-para-elegibilidad-presunta-pe-de-medicaid-new-hampshire-spanish.png "DFA Formulario 821 "Solicitud Para Elegibilidad Presunta (Pe) De Medicaid" - New Hampshire (Spanish)")
![DFA Form 820 "Request to Determine Presumptive Eligibility (Pe)" - New Hampshire](https://data.templateroller.com/pdf_docs_html/1864/18648/1864894/dfa-form-820-request-to-determine-presumptive-eligibility-pe-new-hampshire.png "DFA Form 820 "Request to Determine Presumptive Eligibility (Pe)" - New Hampshire")
![DFA Form 752 "Physician/Psychologist Statement of Capabilities" - New Hampshire](https://data.templateroller.com/pdf_docs_html/1863/18636/1863639/dfa-form-752-physician-psychologist-statement-of-capabilities-new-hampshire.png "DFA Form 752 "Physician/Psychologist Statement of Capabilities" - New Hampshire")
DFA Form 752 "Physician/Psychologist Statement of Capabilities" - New Hampshire
Size: 299 KB
4 pages
![DFA Form 773 "Certification of Continued Absence" - New Hampshire](https://data.templateroller.com/pdf_docs_html/1866/18668/1866893/dfa-form-773-certification-of-continued-absence-new-hampshire.png "DFA Form 773 "Certification of Continued Absence" - New Hampshire")
![DFA Form 720 "Determination of Incapacity Status" - New Hampshire](https://data.templateroller.com/pdf_docs_html/1866/18668/1866890/dfa-form-720-determination-of-incapacity-status-new-hampshire.png "DFA Form 720 "Determination of Incapacity Status" - New Hampshire")
![DFA Form 770 "Reimbursement Agreement and Acknowledgment" - New Hampshire](https://data.templateroller.com/pdf_docs_html/1864/18648/1864890/dfa-form-770-reimbursement-agreement-and-acknowledgment-new-hampshire.png "DFA Form 770 "Reimbursement Agreement and Acknowledgment" - New Hampshire")
![DFA Formulario 773 "Certificacion De Ausencia Continua" - New Hampshire (Spanish)](https://data.templateroller.com/pdf_docs_html/1875/18753/1875384/dfa-formulario-773-certificacion-de-ausencia-continua-new-hampshire-spanish.png "DFA Formulario 773 "Certificacion De Ausencia Continua" - New Hampshire (Spanish)")
![DFA Form 752A "Authorization for Release of Protected Health Information for the Use and Disclosure of Individually Indentifiable Health Information" - New Hampshire](https://data.templateroller.com/pdf_docs_html/1863/18636/1863644/dfa-form-752a-authorization-for-release-of-protected-health-information-for-the-use-and-disclosure-of-individually-indentifiable-health-information-new-hampshire.png "DFA Form 752A "Authorization for Release of Protected Health Information for the Use and Disclosure of Individually Indentifiable Health Information" - New Hampshire")
![DFA Formulario 800MA "Solicitud De Cobertura De Salud Y Ayuda Para Pagar Los Costos" - New Hampshire (Spanish)](https://data.templateroller.com/pdf_docs_html/1875/18753/1875383/dfa-formulario-800ma-solicitud-de-cobertura-de-salud-y-ayuda-para-pagar-los-costos-new-hampshire-spanish.png "DFA Formulario 800MA "Solicitud De Cobertura De Salud Y Ayuda Para Pagar Los Costos" - New Hampshire (Spanish)")
![DFA Form 800FP "Application for Family Planning Medical Assistance (Fpma)" - New Hampshire](https://data.templateroller.com/pdf_docs_html/1864/18648/1864895/dfa-form-800fp-application-for-family-planning-medical-assistance-fpma-new-hampshire.png "DFA Form 800FP "Application for Family Planning Medical Assistance (Fpma)" - New Hampshire")
![Form 1004D "Presumptive Eligibility (Pe) Cfi/Hcbc Application Cover Sheet for Medicaid" - New Hampshire](https://data.templateroller.com/pdf_docs_html/1864/18648/1864888/form-1004d-presumptive-eligibility-pe-cfi-hcbc-application-cover-sheet-for-medicaid-new-hampshire.png "Form 1004D "Presumptive Eligibility (Pe) Cfi/Hcbc Application Cover Sheet for Medicaid" - New Hampshire")
![DFA Form 800 INSERT "Medical Assistance for Children, Pregnant Women, & Parent/Caretaker Relatives Insert" - New Hampshire](https://data.templateroller.com/pdf_docs_html/2212/22123/2212381/dfa-form-800-insert-medical-assistance-for-children-pregnant-women-parent-caretaker-relatives-insert-new-hampshire.png "DFA Form 800 INSERT "Medical Assistance for Children, Pregnant Women, & Parent/Caretaker Relatives Insert" - New Hampshire"){kind=icon}
![DFA Formulario 800(INSERT) "Inserto De Asistencia Medica Para Ninos, Mujeres Embarazadas Y Padres/Parientes Cuidadores" - New Hampshire (Spanish)](https://data.templateroller.com/pdf_docs_html/1875/18753/1875373/dfa-formulario-800-insert-inserto-de-asistencia-medica-para-ninos-mujeres-embarazadas-y-padres-parientes-cuidadores-new-hampshire-spanish.png "DFA Formulario 800(INSERT) "Inserto De Asistencia Medica Para Ninos, Mujeres Embarazadas Y Padres/Parientes Cuidadores" - New Hampshire (Spanish)")
!["Unresolved Food Stamp Complaints" - New Hampshire](https://data.templateroller.com/pdf_docs_html/2151/21517/2151716/unresolved-food-stamp-complaints-new-hampshire.png ""Unresolved Food Stamp Complaints" - New Hampshire")