DFA Form 752A "Authorization for Release of Protected Health Information for the Use and Disclosure of Individually Indentifiable Health Information" - New Hampshire

What Is DFA Form 752A?

This is a legal form that was released by the New Hampshire Department of Health and Human Services - Division of Family Assistance - a government authority operating within New Hampshire. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2015;
  • The latest edition provided by the New Hampshire Department of Health and Human Services - Division of Family Assistance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DFA Form 752A by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Health and Human Services - Division of Family Assistance.

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Download DFA Form 752A "Authorization for Release of Protected Health Information for the Use and Disclosure of Individually Indentifiable Health Information" - New Hampshire

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NH Department of Health & Human Services (DHHS)
DFA Form 752A
Division of Family Assistance (DFA)
12/10 Rev 1/15
A
R
P
H
I
UTHORIZATION FOR
ELEASE OF
ROTECTED
EALTH
NFORMATION
F
OR THE USE AND DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
What happens when you are temporarily unable to or limited in your ability to participate in the
New Hampshire Employment Program (NHEP)?
You have told us that your or your family member’s health condition is a barrier to your participation in
NHEP, the work program designed to help you prepare for and find employment. Your healthcare
provider must provide us with documentation about your health condition so that it can be determined if
you are fully, partially, or totally unable to participate in NHEP. You will receive two important forms to
assist you with this:
1. This form, DFA Form 752A, Authorization for Release of Protected Health Information, which, with
your permission, allows us to receive medical information from your healthcare provider(s); and
2. DFA Form 752, Physician/Clinician Statement of Capabilities, OR DFA Form 752HH,
Physician/Clinician Statement of Necessary Patient Care For a Household Member, which your
healthcare provider needs to complete and send directly to the Medical Exemption Unit (MEU) to
document your or a family member’s medical condition. The information your healthcare provider
enters onto DFA Form 752/752HH will help us determine your ability to participate in NHEP or
whether other programs may better help you with your healthcare needs.
You must sign DFA Form 752A and give it to your healthcare provider(s), while DFA Form
752/752HH must be filled out by your healthcare provider who must then return it directly to us.
You are responsible for making sure that DFA Form 752A and DFA Form 752/752HH get to your
healthcare provider. If you are applying or reapplying for Financial Assistance To Needy Families,
DFA Form 752/752HH must be returned within 10 days of the date on the notice granting your
eligibility. Otherwise, if you already participate in NHEP, you must continue to participate until
DFA Form 752/752HH is returned and a decision is made on your status.
What you need to do:
If your health condition limits your participation in NHEP, review and sign DFA Form 752A. Make a
copy of it or keep the yellow sheet. Give the original signed DFA Form 752A and the DFA Form 752
to your healthcare provider.
If your family member’s health condition limits your participation in NHEP, have the family member
review and sign DFA Form 752A. If the family member is your child, you may review and sign the
DFA Form 752A on behalf of your child. Give the DFA Form 752HH and the original signed DFA
Form 752A to your healthcare provider.
Send the copy of the signed DFA Form 752A to DFA, NH DHHS, 129 Pleasant Street, Brown Bldg,
Concord, NH 03301-3857, Attn: Medical Exemption Unit (MEU).
Tell your healthcare provider that he or she must return the completed DFA Form 752/752HH directly
to us within 10 days or you will be required to participate in work activities.
Let us know if you are having difficulty in getting your healthcare provider to complete the form.
Once you have been found eligible for financial assistance, your medical information will be reviewed
and, depending on your medical situation, a specialist from our Department may contact you and/or your
doctor to determine if you have any ability to participate in the many activities and services offered by
NHEP. The specialist may also identify other services that can help your family’s specific medical
situation.
If we do not receive a completed DFA Form 752/752HH directly from your healthcare provider, or your
doctor has indicated that you can participate in NHEP, you will receive a letter scheduling you to attend a
required NHEP appointment. If you have any questions about this process, you can contact the Medical
Exemption Unit (MEU) at 1-800-852-3345 Ext. 9511.
Payment of any separate charge for completing this form is the responsibility of the patient. Charges solely for the
completion of medical forms will not be paid by the Department of Health & Human Services.
DFA SR 10-40
(N/A)
NH Department of Health & Human Services (DHHS)
DFA Form 752A
Division of Family Assistance (DFA)
12/10 Rev 1/15
A
R
P
H
I
UTHORIZATION FOR
ELEASE OF
ROTECTED
EALTH
NFORMATION
F
OR THE USE AND DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
What happens when you are temporarily unable to or limited in your ability to participate in the
New Hampshire Employment Program (NHEP)?
You have told us that your or your family member’s health condition is a barrier to your participation in
NHEP, the work program designed to help you prepare for and find employment. Your healthcare
provider must provide us with documentation about your health condition so that it can be determined if
you are fully, partially, or totally unable to participate in NHEP. You will receive two important forms to
assist you with this:
1. This form, DFA Form 752A, Authorization for Release of Protected Health Information, which, with
your permission, allows us to receive medical information from your healthcare provider(s); and
2. DFA Form 752, Physician/Clinician Statement of Capabilities, OR DFA Form 752HH,
Physician/Clinician Statement of Necessary Patient Care For a Household Member, which your
healthcare provider needs to complete and send directly to the Medical Exemption Unit (MEU) to
document your or a family member’s medical condition. The information your healthcare provider
enters onto DFA Form 752/752HH will help us determine your ability to participate in NHEP or
whether other programs may better help you with your healthcare needs.
You must sign DFA Form 752A and give it to your healthcare provider(s), while DFA Form
752/752HH must be filled out by your healthcare provider who must then return it directly to us.
You are responsible for making sure that DFA Form 752A and DFA Form 752/752HH get to your
healthcare provider. If you are applying or reapplying for Financial Assistance To Needy Families,
DFA Form 752/752HH must be returned within 10 days of the date on the notice granting your
eligibility. Otherwise, if you already participate in NHEP, you must continue to participate until
DFA Form 752/752HH is returned and a decision is made on your status.
What you need to do:
If your health condition limits your participation in NHEP, review and sign DFA Form 752A. Make a
copy of it or keep the yellow sheet. Give the original signed DFA Form 752A and the DFA Form 752
to your healthcare provider.
If your family member’s health condition limits your participation in NHEP, have the family member
review and sign DFA Form 752A. If the family member is your child, you may review and sign the
DFA Form 752A on behalf of your child. Give the DFA Form 752HH and the original signed DFA
Form 752A to your healthcare provider.
Send the copy of the signed DFA Form 752A to DFA, NH DHHS, 129 Pleasant Street, Brown Bldg,
Concord, NH 03301-3857, Attn: Medical Exemption Unit (MEU).
Tell your healthcare provider that he or she must return the completed DFA Form 752/752HH directly
to us within 10 days or you will be required to participate in work activities.
Let us know if you are having difficulty in getting your healthcare provider to complete the form.
Once you have been found eligible for financial assistance, your medical information will be reviewed
and, depending on your medical situation, a specialist from our Department may contact you and/or your
doctor to determine if you have any ability to participate in the many activities and services offered by
NHEP. The specialist may also identify other services that can help your family’s specific medical
situation.
If we do not receive a completed DFA Form 752/752HH directly from your healthcare provider, or your
doctor has indicated that you can participate in NHEP, you will receive a letter scheduling you to attend a
required NHEP appointment. If you have any questions about this process, you can contact the Medical
Exemption Unit (MEU) at 1-800-852-3345 Ext. 9511.
Payment of any separate charge for completing this form is the responsibility of the patient. Charges solely for the
completion of medical forms will not be paid by the Department of Health & Human Services.
DFA SR 10-40
(N/A)
NH Department of Health & Human Services (DHHS)
DFA Form 752A
Division of Family Assistance (DFA)
12/10 rev 1/15
A
R
P
H
I
UTHORIZATION FOR
ELEASE OF
ROTECTED
EALTH
NFORMATION
F
OR THE USE AND DISCLOSURE OF INDIVIDUALLY INDENTIFIABLE HEALTH INFORMATION
– A
P
FANF
, R
I
(RID)
, &
LEASE PRINT THE
INDIVIDUAL
S NAME
ECIPIENT
DENTIFICATION
NUMBER
CASE NUMBER
LSO PRINT THE FAMILY MEMBER
S NAME IF
FANF
.
THE
INDIVIDUAL IS CLAIMING A MEDICAL EXEMPTION FOR CARING FOR A HOUSEHOLD MEMBER
FANF Individual
RID #
Family Member Name, if applicable
Case #
I hereby authorize the use or disclosure of my individually identifiable health information as
described below. I understand that the information I authorize a person or entity to receive may be re-
disclosed and no longer protected by federal privacy regulations.
This authorization expires 12-months from the date this form is signed.
Persons/organizations authorized to use and/or disclose the information: Health Care Provider
Persons/organizations authorized to receive the information: New Hampshire Department of Health
& Human Services (DHHS), including contract staff.
Specific description of information that may be used/disclosed: Information specifying capacities,
environments, activities and/or limitations to participate in New Hampshire Employment Program (NHEP)
work-related activities such as job readiness classes, education, vocational training, on-the-job training
and actual employment.
The information will be used/disclosed for the following purposes: Information will be used to
determine the individual’s ability to participate in any work-related activities available through NHEP.
I understand that this authorization is voluntary and that I may refuse to sign this authorization. I further
understand that my refusal to sign this authorization may result in a determination that I am a mandatory
participant in the NHEP work program. I understand that I may revoke this authorization at any time by
notifying DHHS in writing. However, the revocation will not be valid if:
1. DHHS has already taken action based upon this authorization; or
2. This authorization is obtained as a condition for obtaining insurance coverage; other law provides
the insurer with the right to contest a claim under the policy or the policy itself.
Please sign below.
Signature of Applicant/Recipient/Family Member or Authorized Representative
Date
Printed Name of Applicant/Recipient/Family Member or Authorized Representative
If the individual signing the release is an authorized representative, please attach the appropriate legal
documentation, such as the DFA Form 778, Authorized Representative (AR) Declaration.
For DHHS Use Only
If the individual signing this release is an authorized representative, your signature below certifies that
you have verified the authorized representative’s identity.
Signature/Title
Date
DFA SR 10-40
Yellow/Copy – MEU
White/Original - Healthcare Provider
(5YC)
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