Division of Family Assistance Applications & Forms
The Division of Family Assistance recently launched NH EASY, New Hampshire's Electronic Application System. Learn how to apply for assistance, check eligibility, track your application status and more by visiting the NH EASY web page.
Applications
- Application for Assistance (Form 800) (English) (Spanish) (Bosnian)
- Authorized Representative (Form 778) (English) (Spanish) (Bosnian)
- Application for Children's Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW) (Form 800P) (English) (Spanish) (Nepali)
- Your Rights & Responsibilities (Form 811R) (English) (Spanish) (Nepali)
Verifications
- Authorization for Release of Protected Health Information (Form 752A)
(English) (Spanish) (Bosnian)
- Eligibility Verifications (Form 800V) (English) (Spanish) (Bosnian)
- Employment Verification (Form 756)
- Non-Medical Evaluation of Disability-DDU (Form 177)
- Physician/Clinician Statement of Capabilities (Form 752)
- Physician/Clinician Statement of Necessary Patient Care (Form 752HH)
- Rental Verification (Form 775)
- Certification of Continued Absence (Form 773) (English) (Spanish) (Bosnian)
- Determination of Incapacity Status (Form 720)
Additional Information
- Family Assistance Fact Sheet (effective 03/01/2013)
- Income Limits by Program (effective 03/01/2013)
- Instructions for Physician/Clinician Statement of Capabilities, Physician/Clinician Statement of Necessary Patient Care and Authorization for Release of Protected Health Information
Adobe Acrobat Reader format. You can download a free reader from Adobe.