BFA Form 752 "Physician/Clinician Statement of Capabilities" - New Hampshire

What Is BFA Form 752?

This is a legal form that was released by the New Hampshire Department of Health and Human Services - Bureau 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 June 1, 2019;
  • The latest edition provided by the New Hampshire Department of Health and Human Services - Bureau 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 BFA Form 752 by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance.

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Download BFA Form 752 "Physician/Clinician Statement of Capabilities" - New Hampshire

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NH Department of Health and Human Services (DHHS)
BFA Form 752
Bureau of Family Assistance (BFA)
06/19
Name of FANF applicant/recipient
RID # and/or Case # (if known)
Medical Exemption Unit
Bureau of Family Assistance, DHHS
129 Pleasant Street, Brown Building
Concord, NH 03301-3857
Fax: (603) 271-4637
The Financial Assistance to Needy Families (FANF) program requires individuals to participate for a minimum of
20 to 30 hours per week in activities that help prepare them for self-sustaining, unsubsidized employment.
The individual named above reports that he or she is either limited or unable to participate in activities due to a
medical and/or psychological condition. We need your professional assessment to help us determine this
-related activities.
Only the following currently licensed healthcare providers are authorized to complete and sign this form:
Physicians, Physician Assistants, Advanced Practice Registered Nurses, Alcohol and Drug Counselors (Master
LADCs only), Psychologists (board certified), Pastoral Psychotherapists, Independent Clinical Social Workers,
Clinical Mental Health Counselors, and Marriage and Family Therapists.
The attached form has 2 sections. Please complete and return the appropriate section(s):
Section 1: For healthcare providers treating a physical condition.
Section 2: For healthcare providers treating a psychological condition.
Your patient should provide you with a signed Authorization for Release of Protected Health Information for FANF
Financial Assistance (BFA Form 752A) providing permission to release the information on this form (BFA Form
752) to DHHS. Please fax or mail this completed form (BFA Form 752) directly to the Medical Exemption Unit
using the contact information above.
If you have any questions, please call the Medical Exemption Unit at (603) 271-9511, option 2.
Preparatory and Work-Related Activities
There are many preparatory and work-related activities offered to individuals in the FANF work program.
Individuals can participate in activities adapted to meet his or her needs and abilities. Activities include:
Barrier resolution: This may include counseling or other services designed to minimize or resolve a personal
issue or other barriers to employment.
Education or training: This may include basic or adult education, ESL, or other education or training
programs that promote employability.
Work-related activities: This may include paid or unpaid work, or structured, supervised work activities that
provide the individual the opportunity to experience and acquire the general workplace behaviors, attitudes,
skills, and knowledge necessary to obtain and retain paid work.
Once completed, this form is valid for up to 6 months.
1
BFA SR 19-28
(6YC)
NH Department of Health and Human Services (DHHS)
BFA Form 752
Bureau of Family Assistance (BFA)
06/19
Name of FANF applicant/recipient
RID # and/or Case # (if known)
Medical Exemption Unit
Bureau of Family Assistance, DHHS
129 Pleasant Street, Brown Building
Concord, NH 03301-3857
Fax: (603) 271-4637
The Financial Assistance to Needy Families (FANF) program requires individuals to participate for a minimum of
20 to 30 hours per week in activities that help prepare them for self-sustaining, unsubsidized employment.
The individual named above reports that he or she is either limited or unable to participate in activities due to a
medical and/or psychological condition. We need your professional assessment to help us determine this
-related activities.
Only the following currently licensed healthcare providers are authorized to complete and sign this form:
Physicians, Physician Assistants, Advanced Practice Registered Nurses, Alcohol and Drug Counselors (Master
LADCs only), Psychologists (board certified), Pastoral Psychotherapists, Independent Clinical Social Workers,
Clinical Mental Health Counselors, and Marriage and Family Therapists.
The attached form has 2 sections. Please complete and return the appropriate section(s):
Section 1: For healthcare providers treating a physical condition.
Section 2: For healthcare providers treating a psychological condition.
Your patient should provide you with a signed Authorization for Release of Protected Health Information for FANF
Financial Assistance (BFA Form 752A) providing permission to release the information on this form (BFA Form
752) to DHHS. Please fax or mail this completed form (BFA Form 752) directly to the Medical Exemption Unit
using the contact information above.
If you have any questions, please call the Medical Exemption Unit at (603) 271-9511, option 2.
Preparatory and Work-Related Activities
There are many preparatory and work-related activities offered to individuals in the FANF work program.
Individuals can participate in activities adapted to meet his or her needs and abilities. Activities include:
Barrier resolution: This may include counseling or other services designed to minimize or resolve a personal
issue or other barriers to employment.
Education or training: This may include basic or adult education, ESL, or other education or training
programs that promote employability.
Work-related activities: This may include paid or unpaid work, or structured, supervised work activities that
provide the individual the opportunity to experience and acquire the general workplace behaviors, attitudes,
skills, and knowledge necessary to obtain and retain paid work.
Once completed, this form is valid for up to 6 months.
1
BFA SR 19-28
(6YC)
NH Department of Health and Human Services (DHHS)
BFA Form 752
Bureau of Family Assistance (BFA)
06/19
(Complete if treating a physical condition.)
Only the following currently licensed healthcare providers are authorized to complete and sign this form for
physical abilities please check the corresponding box to indicate your profession:
Physician
Physician Assistant
Advanced Practice Registered Nurse
Diagnosis:
condition limit his or her activities?
activities by circling the appropriate answer:
Can perform sedentary activities. This includes frequent sitting or occasional standing/walking,
Yes
No
such as classroom situations, desk work, and counseling or other appointments.
Can perform light work activities. This includes frequent walking, lifting of objects weighing 10
Yes
No
pounds, or the operation of simple equipment.
Can perform medium work activities. This includes frequent reaching, bending, or lifting of
Yes
No
objects weighing 25 pounds and activities involving fine manual dexterity or coordination.
Can perform heavy work activities. This includes frequent physical exertion in a taxing work
Yes
No
position, such as lifting and dragging heavy objects weighing 50 pounds or more.
With normal breaks, please indicate the maximum daily time the patient can:
Activity
None
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours
7 hours
8+ hours
Sit
Stand
Walk
Is the patient taking any medication that negatively affects his or her abilities?
No
Yes
Please list any limitations or accommodations:
With the above-noted accommodations in place (if any), is the patient able to participate in educational,
training, or work-related activities?
No
Yes
If yes, indicate the number of hours the patient can participate per week:
31 or more hours
26 to 30 hours
21 to 25 hours
20 hours
1 to 19 hours
Authorized healthcare provider signature
Date
Phone
Authorized healthcare provider printed name (with credentials)
2
Payment of any separate charge for completing this form is the responsibility of the patient.
NH Department of Health and Human Services (DHHS)
BFA Form 752
Bureau of Family Assistance (BFA)
06/19
(Complete if treating a psychological condition.)
Only the following currently licensed healthcare providers are authorized to complete and sign this form for
psychological abilities please check the corresponding box to indicate your profession:
Physician
Physician Assistant
APRN
Psychologist (board certified)
Clinical Mental Health Counselor
Pastoral Psychotherapist
Independent Clinical Social Worker
Alcohol and Drug Counselor (MLADC only)
Marriage and Family Therapist
Diagnosis:
For each activity listed below, rate the
limitation in each area using the following terms:
None
No deficit; ability is not limited
Mild
Individual can perform the activity satisfactorily most of the time
Moderate
Individual can perform the activity satisfactorily some of the time
Marked
Individual has no useful ability to function
Activity
None
Mild
Moderate
Marked
Interact appropriately with others
Maintain socially acceptable behavior
Ask questions or request help when necessary
Adhere to basic standards of neatness and hygiene
Aware of normal hazards; take precautions
Remember locations and work-like procedures
Understand and remember short, simple instructions
Maintain attention for extended periods
Sustain routine without frequent supervision
Make simple work-related decisions
Concentrate, persist, or maintain pace
Adapt to change
Is the patient taking any medication that negatively affects his or her abilities?
No
Yes
Please list any limitations or accommodations:
With the above-noted accommodations in place (if any), is the patient able to participate in educational,
training, or work-related activities?
No
Yes
If yes, indicate the number of hours the patient can participate per week:
31 or more hours
26 to 30 hours
21 to 25 hours
20 hours
1 to 19 hours
Authorized healthcare provider signature
Date
Phone
Authorized healthcare provider printed name (with credentials)
3
Payment of any separate charge for completing this form is the responsibility of the patient.
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