BFA Form 752HH "Healthcare Provider Statement of Necessary Care for a Fanf Household Member" - New Hampshire

What Is BFA Form 752HH?

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 752HH 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 752HH "Healthcare Provider Statement of Necessary Care for a Fanf Household Member" - New Hampshire

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NH Department of Health and Human Services (DHHS)
BFA Form 752HH
Bureau of Family Assistance (BFA)
06/19
Healthcare Provider Statement of Necessary Care for a FANF Household Member
Name: FANF recipient or applicant
RID # and/or Case # (if known)
Authorized healthcare provider:
Please return via mail or fax to:
Name:
Medical Exemption Unit
Bureau of Family Assistance, DHHS
129 Pleasant Street, Brown Building
Address:
Concord, NH 03301-3857
Phone:
Fax: (603) 271-4637
You are receiving this form because you are a healthcare provider for:
Household member (patient)
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 FANF recipient named at the top of this form reports that your patient is a member of the household who
requires the FANF recipient to be at home to provide care, and that this care partially or completely limits the
FANF recipient
to participate in education, training, and other work-related activities. We need your
professional assessment to help us determine if this FANF recipient has the ability to participate in preparatory
and work-related activities.
Who qualifies as a household member? A household member must live in the same house as the FANF
recipient and be either a relative of the FANF recipient or a member of the FANF assistance group.
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.
Your patient should provide you with a signed Authorization for Release of Protected Health Information for
FANF Financial Assistance (BFA Form 752A) providing permission for you to release the information in this
form (BFA Form 752HH) to DHHS. Please fax or mail this completed form (BFA Form 752HH) 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.
BFA SR 19-28
Payment of any separate charge for completing this form is the responsibility of the patient.
(6YC)
NH Department of Health and Human Services (DHHS)
BFA Form 752HH
Bureau of Family Assistance (BFA)
06/19
Healthcare Provider Statement of Necessary Care for a FANF Household Member
Name: FANF recipient or applicant
RID # and/or Case # (if known)
Authorized healthcare provider:
Please return via mail or fax to:
Name:
Medical Exemption Unit
Bureau of Family Assistance, DHHS
129 Pleasant Street, Brown Building
Address:
Concord, NH 03301-3857
Phone:
Fax: (603) 271-4637
You are receiving this form because you are a healthcare provider for:
Household member (patient)
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 FANF recipient named at the top of this form reports that your patient is a member of the household who
requires the FANF recipient to be at home to provide care, and that this care partially or completely limits the
FANF recipient
to participate in education, training, and other work-related activities. We need your
professional assessment to help us determine if this FANF recipient has the ability to participate in preparatory
and work-related activities.
Who qualifies as a household member? A household member must live in the same house as the FANF
recipient and be either a relative of the FANF recipient or a member of the FANF assistance group.
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.
Your patient should provide you with a signed Authorization for Release of Protected Health Information for
FANF Financial Assistance (BFA Form 752A) providing permission for you to release the information in this
form (BFA Form 752HH) to DHHS. Please fax or mail this completed form (BFA Form 752HH) 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.
BFA SR 19-28
Payment of any separate charge for completing this form is the responsibility of the patient.
(6YC)
NH Department of Health and Human Services (DHHS)
BFA Form 752HH
Bureau of Family Assistance (BFA)
06/19
Necessary Patient Care
(Complete if treating a FANF recipient
member.)
Only the following currently licensed healthcare providers are authorized to complete and sign this form
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
Your patient lives with a FANF recipient who has indicated an inability to participate in required preparatory and
work-related activities due to his or her need to be in the home to care for your patient. To help us determine if the
FANF recipient is eligible for this type of exemption, please provide the following information:
Patient (household member)
FANF recipient (needed to care for patient)
Relationship to patient
is or her activities?
In a 24-hour period, how many hours of care are needed for your patient?
0 to 1
1 to 3
3 to 6
6+
Daily living skills, such as bathing, feeding, dressing
Administration of medications
Observing/monitoring behavior/medical conditions
Other
Indicate any medical, school, therapy, or other appointments that require a caretaker to accompany your patient:
Number of appointments:
Frequency:
1. Does the
at home to provide/assist with daily care?
Yes
No
Yes
No
2. Is the FANF recipient named above the only appropriate household member to
provide the necessary care for your patient?
Yes
No
3. If the patient is a minor, are there functional limitations that prevent your patient from
attending childcare or before- or after-school programs?
If yes, explain:
Yes
No
4. Are any accommodations needed for the FANF recipient
relating to the patient?
If yes, explain:
5. With the above-noted accommodations in place (if any), how many hours per week is the FANF applicant/
recipient available to participate in preparatory or work-related activities?
31 or more hours
26 to 30 hours
21 to 25 hours
20 hours
1 to 19 hours
None
6. How long will your patient need this level of care (in months)?
Date
Phone
Authorized healthcare provider signature
Authorized healthcare provider printed name (with credentials)
BFA SR 19-28
Payment of any separate charge for completing this form is the responsibility of the patient.
(6YC)
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