BFA Form 752A "Authorization for Release of Protected Health Information for Fanf Financial Assistance" - New Hampshire

What Is BFA Form 752A?

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;
  • Available in Spanish;
  • 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 752A 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 752A "Authorization for Release of Protected Health Information for Fanf Financial Assistance" - New Hampshire

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NH Department of Health and Human Services (DHHS)
BFA Form 752A
Bureau of Family Assistance (BFA)
06/19
Authorization for Release of Protected Health Information for FANF Financial Assistance
You applied for help from the Financial Assistance to Needy Families (FANF) program. FANF has rules that you
must work or do something like education or training that helps you get ready for work. This part of FANF is called
the New Hampshire Employment Program (NHEP).
You told us that your health problem (or your household
problem) makes it too hard to do NHEP.
We need some information to learn if your health problem (or your household
) is bad
enough to limit or end your NHEP activities. Two forms are needed so that DHHS can get this information.
Read the first box if you have the health problem. Read the second box if your household member has the
health problem. Then keep reading below the boxes.
you have a health problem?
1. Read and sign the other side of this form to let your healthcare provider share health information with
DHHS (or a company DHHS works with). Give this signed form to your healthcare provider.
2. Also give Form 752, Healthcare Provider Statement of Abilities for FANF Financial Assistance, to your
healthcare provider. Your healthcare provider needs to fill out and sign that form to tell DHHS about your
health problem. Your healthcare provider will return it to us after he or she fills it out.
It is your responsibility to give this form (Form 752A) and Form 752 to your healthcare provider.
your household member has a health problem?
Who counts as a household member? Someone who lives in the same home as you and is either your relative or a
member of your FANF assistance group counts as a household member.
1. Have your household member read and sign the other side of this form to let
healthcare provider share health information with DHHS (or a company DHHS works with). Give this
signed form to
healthcare provider. (If your household member is your child,
you may read and sign this form for your child.)
2. Also give Form 752HH, Healthcare Provider Statement of Necessary Care for a FANF Household
Member, to your household
healthcare provider. The healthcare provider needs to fill out and
sign that form to tell DHHS about your household
household member needs from you. The healthcare provider will return it to us after he or she fills it out.
It is your responsibility to give this form (Form 752A) and Form 752HH
healthcare provider.
Important information:
If you are already in the NHEP program, you must keep doing NHEP activities until DHHS gets Form 752 from
your healthcare provider
and DHHS
decides if the health problem gets in the way of NHEP activities.
If you applied for FANF for the first time, or if you re-applied for FANF, you have 10 calendar days from your
eligibility date to get this signed form to the healthcare provider AND for the healthcare provider to return Form
752 or 752HH to DHHS. (You can find your eligibility date on your Notice of FANF Eligibility.)
Tell the healthcare provider that he or she must return Form 752 or 752HH right to DHHS within 10 calendar
days or else you must do NHEP activities.
If we do not get Form 752 or 752HH from the healthcare provider within 10 calendar days, you will get a letter
with the date and time of a NHEP appointment that you must go to.
If the healthcare provider writes on Form 752 or 752HH that you can do NHEP activities, you will get a letter
with the date and time of a NHEP appointment that you must go to.
Tell us if you are having a hard time getting the healthcare provider to fill out and return Form 752 or 752HH.
If you have any questions, please call
Medical Exemption Unit at 1-800-852-3345, ext. 9511, option 2.
NH Department of Health and Human Services (DHHS)
BFA Form 752A
Bureau of Family Assistance (BFA)
06/19
Authorization for Release of Protected Health Information for FANF Financial Assistance
You applied for help from the Financial Assistance to Needy Families (FANF) program. FANF has rules that you
must work or do something like education or training that helps you get ready for work. This part of FANF is called
the New Hampshire Employment Program (NHEP).
You told us that your health problem (or your household
problem) makes it too hard to do NHEP.
We need some information to learn if your health problem (or your household
) is bad
enough to limit or end your NHEP activities. Two forms are needed so that DHHS can get this information.
Read the first box if you have the health problem. Read the second box if your household member has the
health problem. Then keep reading below the boxes.
you have a health problem?
1. Read and sign the other side of this form to let your healthcare provider share health information with
DHHS (or a company DHHS works with). Give this signed form to your healthcare provider.
2. Also give Form 752, Healthcare Provider Statement of Abilities for FANF Financial Assistance, to your
healthcare provider. Your healthcare provider needs to fill out and sign that form to tell DHHS about your
health problem. Your healthcare provider will return it to us after he or she fills it out.
It is your responsibility to give this form (Form 752A) and Form 752 to your healthcare provider.
your household member has a health problem?
Who counts as a household member? Someone who lives in the same home as you and is either your relative or a
member of your FANF assistance group counts as a household member.
1. Have your household member read and sign the other side of this form to let
healthcare provider share health information with DHHS (or a company DHHS works with). Give this
signed form to
healthcare provider. (If your household member is your child,
you may read and sign this form for your child.)
2. Also give Form 752HH, Healthcare Provider Statement of Necessary Care for a FANF Household
Member, to your household
healthcare provider. The healthcare provider needs to fill out and
sign that form to tell DHHS about your household
household member needs from you. The healthcare provider will return it to us after he or she fills it out.
It is your responsibility to give this form (Form 752A) and Form 752HH
healthcare provider.
Important information:
If you are already in the NHEP program, you must keep doing NHEP activities until DHHS gets Form 752 from
your healthcare provider
and DHHS
decides if the health problem gets in the way of NHEP activities.
If you applied for FANF for the first time, or if you re-applied for FANF, you have 10 calendar days from your
eligibility date to get this signed form to the healthcare provider AND for the healthcare provider to return Form
752 or 752HH to DHHS. (You can find your eligibility date on your Notice of FANF Eligibility.)
Tell the healthcare provider that he or she must return Form 752 or 752HH right to DHHS within 10 calendar
days or else you must do NHEP activities.
If we do not get Form 752 or 752HH from the healthcare provider within 10 calendar days, you will get a letter
with the date and time of a NHEP appointment that you must go to.
If the healthcare provider writes on Form 752 or 752HH that you can do NHEP activities, you will get a letter
with the date and time of a NHEP appointment that you must go to.
Tell us if you are having a hard time getting the healthcare provider to fill out and return Form 752 or 752HH.
If you have any questions, please call
Medical Exemption Unit at 1-800-852-3345, ext. 9511, option 2.
NH Department of Health and Human Services (DHHS)
BFA Form 752A
Bureau of Family Assistance (BFA)
06/19
Authorization for Release of Protected Health Information for FANF Financial Assistance
FANF applicant/recipient name
RID #
Household member name, if applicable
Case #
Purpose of disclosure: This authorization form is to let (authorize) your healthcare provider give (release or
disclose) some of your protected health information to DHHS for the FANF cash assistance program.
Form 752
DHHS uses
the health information listed on Form 752 to learn if you can do NHEP activities, like go to classes or a job.
Form 752 asks about your health problem, how it bothers you, when it started, and how long it might last.
Form 752HH is for your healthcare provider if you are unwell and your household member, who applied for or
already gets FANF, helps take care of you. Form 752HH asks about your health problem, when it started, how
long it might last, and the sorts of things that your household member does to help you.
If you sign this form, you let your healthcare provider give DHHS (or a company DHHS works with) the
information asked for on Form 752 or 752HH. You do not have to sign this form. But, if you do not sign this form,
your healthcare provider cannot share your health information and you (or your household member) may not get
an exemption (a health reason not to do some or all NHEP activities).
Please check all that apply:
I let the healthcare provider I list here share protected health information about my health problem. (See
Form 752 or 752HH for the kinds of providers who may fill out these forms.)
Healthcare provider name:
Company:
Phone:
Address:
I let my healthcare provider share the information listed on Form 752 or 752HH about my health problem,
how it affects me, and the kinds of treatment I get (and for Form 752HH, how it affects my household
member who cares for me).
Some kinds of health information are extra protected. If you want to share
or lines you want to share
I want to share information about my treatment for mental health.
I want to share information about my treatment for substance use disorder.
(Federal law/42 CFR part 2 forbids unauthorized disclosure of these records.)
I want to share information about my treatment for HIV or AIDS.
I let my protected healthcare information listed on Form 752 or Form 752HH be given to: DHHS Medical
Exemption Unit, 129 Pleasant St., Brown Bldg., Concord, NH 03301. Fax: (603) 271-4637.
Federal privacy law says that a form like this one must say that if you sign it and your health information gets
shared (disclosed), you should know the information may be shared again (re-disclosed). However, DHHS will not
share your health information.
What if you change your mind? After you sign this form, you can stop your permission by writing a note to
DHHS. But, DHHS may not get the note until after your healthcare provider already shared the information.
When does my authorization end? It will end one year from the date you sign this form (or earlier, if you ask).
Please sign
to let your healthcare provider share the health information asked for
on Form 752 or Form 752HH.
Signature of FANF applicant/recipient or household member or duly authorized legal representative
Date
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