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DFA SR 07-05 (3YC) Employment Verification (Completed by Employer Only) FROM: Centralized Scanning Unit (CSU) P.O. endobj
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). stream
The State of New Hampshire Employee Assistance Program (EAP) is designed to offer assistance to all State employees and their family members. %PDF-1.5
NH Department of Health & Human Services (DHHS) DDU Form 177 Bureau of Family Assistance (BFA) - Disability Determination Unit (DDU) rev 12/22 Page: 1 of 9 . x=ko9?4_Ei>XLngs{3AX[Jdd?$[-Q>\R*zr[nvr-/?/l\^z|y&y/_di*,QxY|'/~~Kd KxI!T%>-,BJO/_2TNw1=\]?jrK E>;n:E_HJ>Mo6UBNn Click here for our full COVID-19 response. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>>
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Once the scanning procedure is complete, you can resume your regular activities. Tel: +1 201 455 0150. Box 181 Concord, NH 03301 Economic Assistance: (800) 383-4278. We are proud to offer this exam for the everyday price of $79. NH Department of Health and Human Services (DHHS) DFA Form 720 Division of Family Assistance (DFA) 02/13 rev 1/15 DFA SR 13-04 (5YC) DETERMINATION OF INCAPACITY STATUS Name: Return Completed Form to: Centralized Scanning Unit (CSU) Case Number: P.O. For information on available treatment in NH, go to www.covid19.nh.gov/resources/treatment-resources. An RAI representative will be contacting you shortly. x}o7?$s{Cd--644zh=)4EUz?>^/.=^>ybyu?~8_|^vWfW_}V8{OO_9/r+|fO\.B\Wo9N>>'_ '
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Box 181, Concord, NH 03301 DFA SR 11-43 (A) REIMBURSEMENT AGREEMENT AND ACKNOWLEDGMENT Applicant Name: Spouse: Name: (Please print) (Please print) . You'll be asked to hold your breath at certain points in the scan to move the lungs up and out of the way while images are being made. ==c a41j01P
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&UJ4SpTcn! W Pc9Ix {8?fj3J1~9TS'! The health and well-being of patients is our primary concern. Food/Public Accommodations, Jeff Havens, Immunization Information System Training Manager, Vacant, Immunization Information System Interoperability Coordinator, Deb Belleau, Immunization Information System Training & Support, Sarah Lennon, Perinatal Hepatitis B Nurse Consultant, Vacant, Vaccines for Children Quality Specialist, Katie Grady-Selby, Health Education Specialist, Courtney Blaskovich, Financial Specialist,Anthony Littlewhirlwind, STD/HIV Data Entry Specialist, Peggy Baker, Viral Hepatitis Program Manager, Shannon Koenig, STD/HIV Program Evaluator, Brandy Karschnik, HIV/Viral Hepatitis Program Analyst, Gina Tracy, Emergency Management Specialist, Colin Tobin, Health Alert Network Coordinator, Gerry Wheat, Strategic National Stockpile Coordinator, Taylor Curry, ORR Data Specialist/Volunteer Manager, Melissa Burch, Risk Communications Coordinator, Andrea Wingo, Environmental Health Epidemiologist, Abbie Phillip, Environmental Health Assessor, Shuangying Yu, Environment Health Program Specialist, Emma Whitehead, Healthcare Systems Epidemiologist, Vacant, Infection Prevention Specialist, Samantha Carle, Infection Prevention Specialist, Elizabeth Adams, Infection Prevention Specialist, Dianna Bowling, Communicable Disease Nurse Consultant, Jessica Lopeman, Data Acquisition Specialist, Sharon Breidenbach, Adoption/Correction Lead Worker, Mary Suptic, Corrections and Microfilm Clerk, Jenn Rider, Medical Marijuana Lab Sys Improvement Specialist, Kathy Wiegand-Palmer, Medical Marijuana Lab Sys Improvement Specialist, Ian Jacobson, Purchasing/Accounting Tech, Lois Sundblad, Deputy Laboratory Direction/Section Supervisor, Dani Lindeman, Laboratory QA Safety Specialist, Donna Jo Hosmer, Laboratory Data Specialist, Christopher Manning, Micro/Molecular Supervisor, Michelle Mozer, Clinical Laboratory Specialist, Kathy Manion, Clinical Laboratory Specialist, Kelly Barr, Clinical Laboratory Specialist, Ashley Ausman, Clinical Laboratory Specialist, Jaqueline Dixon, Developmental Laboratory Scientist, Joy Ritter, NBS Short-term Follow-up Coordinator, Crystal Fortune, Clinical Lab Specialist, Elizabeth Reynolds, Clinical Lab Technologist, Lorna McIntyre, Clinical Laboratory Specialist, Carla VanderGiessen, Deputy Division Administration, Brandi Loch, Child Abuse Hotline (24 hrs/7 days) Toll Free (In State Only), National Domestic Violence Hotline Toll Free, Grants and Contracts Program Manager, Autumn Beattie, Residential Services Program Officer, Vacant, Chafee Foster Care Independence Program Manager, Elizabeth Bruchez (Lewistown), Centralized Intake Bureau Chief, Laura McCullough, Centralized Intake Specialist Supervisor, Vacant, Centralized Intake Specialist Supervisor, Rachel Rolston, Centralized Intake Specialist Supervisor, Jamie Fortune-Blair, Centralized Intake Specialist Supervisor, Katie Morgan, Centralized Intake Specialist Supervisor, Amanda Morrison, Eastern Region, Miles City, Eric Barnosky, North Central Region, Great Falls, Sahrita Jones-Jessee, North Western Region, Kalispell, Jennifer Blodgett, South Western Region, Butte, Jennifer Hoerauf, Western Region, Missoula, Courtney Callaghan, Administrative Support Supervisor, Angie Smith, Contract Manager, Jo-Anne Rude (Kalispell), Title IV-E Compliance Officer, Lisa Spencer, Title IV-E Compliance Officer, Robet Durrant, Title IV-E Compliance Officer, Cheryl Gran, Title IV-E Compliance Officer, Megan Osborne, Title IV-E Compliance Officer, Cathie Lang, CQI Development Specialist, Sarah Liggett, CQI Development Specialist, Caitlin Stewart-Nurse, Foster Care, Licensing and FRS Bureau Chief, Theresa Becker (Polson), Foster Care & Guardianship Program Manager, Mark Girdler, Permanency Planning Unit Supervisor, Kyla Rock, Adoption Negotiations Manager, Jeanie Weasel Tail, ICPC Deputy Compact Administrator, Lori Hedges, ICPC Deputy Compact Administrator, Kelley Tippett, Post-Adoptions Services Program Manager, Afton Russell, Legal Administrative Support, Janine Whitley, Administrative Support, Gena Geiss-Marton, Main Number - In Helena area or out of state, Employer Relations Specialist, Shawn Rafferty, Federal Tax Offset Specialist, Clarice St Clair, New Hire Directory Specialist, Gary Dahlquist Toll Free, Policy & Procedure Specialist, Jana Maier, Career Development Specialist, Priscilla Hochhalter, Administrative Support, Tanya Mayer-Mlekush, Early Childhood and Family Support Main Number, Early Childhood and Family Support Toll Free Number, Executive Administrative Assistant, Amy McDonald, Child and Adult Care Food Program Toll Free Number, Children's Trust Fund Grant Manager, Joshua Kendrick, Prevention/Early Intervention Program Support, Shari Northcott, Child Care Licensor Anaconda, Michelle Harrington, Child Care Licensor Billings, Ryane Holzwarth, Child Care Licensor Kalispell, Diana Lamers, Child Care Licensor Great Falls, Jodi Linne, Child Carae Licensor Billings, Anna Mason, Child Care Licensor Missoula, Edie McLean, Child Care Licensor Helena, Natalie Mikota, Child Care Licensor Kalispell, Fern Sutherland, Child Care Licensor Bozeman, Teri Whitesitt, Quality Assurance Reviewer, Allison Drake, Child Care Policy and Eligibility Specialist, Chauntel Lucier, Family and Community Health Bureau Administrative Assistant, Kristen Higgins, SRAE and PREP Program Specialist, Jonelle LaPiere, Sexual Assault Prevention & Victim Services, Patrick Paradis, MT Obstetrics Maternal Support Program, Amanda Eby, Title V Maternal, Child Health Block Grant, Blair Lund, Fetal, Infant, Child & Maternal Mortality Review, Kari Tutwiler, Primary Care Office Program Specialist, Annalee Venneri, Outreach & QI Coordinator Program Specialist, Alex Bostrom, Breastfeeding Coordinator Program Specialist, Aimee Duncan, Nutrition Coordinator Program Specialist Lead, Lacy Little, MAPP-NET Program Specialist, Catherine LeMay, Child Care Under the Big Sky, Melody Olson, School Breakfast Coordinator, Linda Cleatus, Communication and Marketing Director, KayAnn Miller, Administrative Support Supervisor, Vena Dagnall, Support Staff Supervisor/MRPO, Kate Miller, Program Manager, Deaf Services, Shawn Tulloch, Transportation Coordinator, Butte, Patrick Sanders, Equipment Distribution Specialist, Missoula, Richard Ballou, Equipment Distribution Specialist, Billings, Mike Bouchard, Assistive Technology Specialist, Paul Suptic, Community Services Program Specialist, Julianna Campbell, CHIMES Security/System Support, Heather Monday, Public Assistance Service Desk / Centralized Scanning Unit Supervisor, Doug O'Dell, Temporary Assistance for Needy Families (TANF) Program Manager, Stephanie Wilkins, Western Region Field Manager, Teri McDonald, Eastern Region Field Manager, Kevin T Frank, Central Region Field Manager, Fred Sullivan, Program Compliance & Training Specialist, Carie Kelly, Commodity Program Specialist, Tina Wagner, Energy & Community Services Program Manager, Marcia Lemon, Energy & Community Services Specialist, Theresa Willard, Energy & Community Services Specialist, Cary Grubb, Energy & Community Services Specialist, Michael Horner, Energy & Community Services Specialist, White Sulphur Springs, Dayna Shepherd, Program Officer, Missoula, Julianna Crowley, Suicide Prevention Coordinator, Karl Rosston, Suicide Prevention Program Specialist, John Tabb, Zero Suicide Grant Manager, Browning, Terrance "TJ" Lafromboise, Prevention Section Supervisor, Kimberly Koch, Mental Health Behavioral Analyst, Deborah Rumberger, Mental Health Eligibility Specialist, Vacant, Special Populations Supervisor, Wyatt McAlpine, Behavioral Health Program Officer, Miranda Griffis, Behavioral Health Program Officer, Missoula, Violet Bolstridge, Program Manager, Missoula, Katie Rasmussen, Medicaid Waiver & State Plan Program Officer, Rena Steyaert, Community Program Officer, Missoula, Jessica Effenberger, Community Program Officer, Miles City, Antonia Klein, Community Program Officer, Missoula, Vacant, Contract and Fiscal Officer, Justin Harris, School Based Services Program Officer, Christine White, Administrative Assistant, Alisha Oellermann, Licensed Clinician, Billings, Anthony Killebrew, Utilization Review Technician, Alana Wilson, Regional Resource Specialist, Helena, Theresa Holm, Regional Resource Specialist, Missoula, Trish Christensen, Medicaid Program Supervisor, Renae Huffman, Grants & Contracts Manager, Stephanie Kindt, Information System Specialist, Chet Williams, Psychiatric Consultant, Dr Michelle McCall, Behavior Consultation Team Supervisor, Connie Orr, Behavior Consultation Specialist, Billings, Cheryl Nystrom, Community Service Supervisor, Shannon Cole-Merchen, Medicaid Program Officer/Transition Specialist, Suzanne Rowe, Medicaid Program Officer/Waiver Specialist, Barbara Doggett, Medicaid Program Officer/Waiver Specialist, Carla Rime, Medicaid Prior Authorization Toll Free Number, Medicaid Transportation Services Toll Free Number, Montana Healthcare Programs Member Helpline, Montana Healthcare Programs Provider Relations Helpline, To Report Medicaid Provider Fraud Toll Free Number, To Report Suspected Medicaid Member Fraud Toll Free Number, Conduent (Montana only) Medicaid Claims Payment Contractor Toll Free Number, IHS/Tribal 638 Program Officer, Jacqui Roberts, Medicaid Operations Research Section Supervisor, Renee Quintana, Medicaid Operations Research Analyst, Vacant, Medicaid Operations Research Analyst, Emily Hollow, Medicaid Operations Research Analyst, Julie Bullman, Medicaid Operations Research Analyst, Trisha Goettle, Allied Health Claims Resolution/DME/Dental, Vacant, Dental & Transportation Program Officer, Lynea Linz, Durable Medical Equipment, Hearing Aid & Audiology Program Officer, Maggie Irby, School Based Services, Optometric, Eyeglasses, Occupational Therapy, Speech Therapy, and Physical Therapy Program Officer, Laurie Nelson, Pharmacy Assistance Supervisor, Christina David, Drug Rebate Program Coordinator, Amber Pierce, Drug Rebate Program Specialist, Shirley 'Michaelanne' Fagnan, Drug Rebate Program Specialist, Ariel Scotton, Hospital Claims Resolution, Amanda Brensdal, Physician Program Officer, Stephanie King, Meadowlark Initiative and PRISM for MOMS Program Officer, vacant, State Plan & Medicaid Waiver, Plan First, WASP, HELP Program Officer, Linda Skiles-Hadduck, Primary Care and Population Health, Passport, CPC+ and PCMH Program Officer, Liz Lelacheur, Healthy Montana Kids Program Officer, Michael Mahoney, Healthy Montana Kids Program Officer, Krista Pratt, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program Specialist; Targeted Case Management (TCM Non-Mental Health); Team Care Program, Miranda Prevel, Medicaid Reform Initiative Specialist, Traci Clark, BSW, Adult Protective Services Toll Free Intake Number, Adult Protective Services Region 1 Supervisor, Jody McCampbell, Adult Protective Services Region 2 Supervisor, Sabrina McQuinn, Adult Protective Services Region 3 Supervisor, Janice Hinze, Adult Protective Services Region 4 Supervisor, Glenda Oestreicher, Director, State Unit on Aging, Kerrie Reidelbach, State Long term Care Ombudsman Program Manager, Carmen Sciabica, State Health Insurance and Assistance Program Director, Janet Stellmon, Program Manager, Michael Woods (Great Falls), Program Manager, Michaelene 'Micky' Brown, Facility Based Section Supervisor, Derik Sapp (Great Falls), Financial Technical Analyst, Samantha Cooley, Financial Transparency Specialist, Monique England, Montana Mental Health Nursing Care Center and Intensive Behavior Center Financial Investigator, Daryl Hickey, Montana Chemical Dependency Center and Montana Veterans Home Financial Investigator, Peggy Bennetts, Montana State Hospital Financial Investigator, Calvin Trainor, Montana State Hospital Financial Investigator, Krista Henderson, Logistics Coordinator - Mail, Tim Isaacson, Logistics Coordinator - Mail, Chris Herman, Logistics Coordinator - Surplus, Don Bartsch, Logistics Coordinator - Surplus, Brian Johnson, Accounting Technician, Dustin Hendrickson, Records and Lease Specialist, Theresa Rush, AR & Internal Control Specialist, Beth Lewis, Accounting Technician (Med Needy), Emma Frydenlund, Life Safety Code, Emergency Preparedness, CLIA Supervisor Tony Sanfilippo, Health Facility Surveyor, Rachelle Jewison, Health Facility Surveyor, David J. Rankosky, Acute & Continuing Care /Complaint/Dispute Resolution Manager, Tyler Smith, Health Facility Surveyor, Jennifer Anderson, Nursing Facilities Abuse Hotline Toll Free Number, Healthcare Facility Program Manager, Tara Wooten, Residential Care Program Manager, Anaconda, Julie Fink, Residential Care Licensing Surveyor, Bryan Greer, Residential Care Licensing Surveyor, Stephanie Galle, Residential Care Licensing Surveyor, Christopher Sowell, Residential Care Licensing Surveyor, Sabrina Charlson, Residential Care Licensing Surveyor, Teresa Burtell, Residential Care Licensing Surveyor, Kara Seyer, Payment Error Rate Measurement (PERM), Shauna Longmire, Quality Control Team Lead, Heather Kerker, Quality Control Auditor, Kristyn Anderson, Quality Control Auditor, Ashley Alexander, IPV/ MEQC / PERM Supervisor, Heather Smith, Program Integrity Specialist, Christen LeBlanc-Birkholz, Program Integrity Investigator, Yvonne Perry, Program Integrity Investigator, Lana Madsen, Program Integrity Investigator, Nancy White, Program Integrity Investigator, Cassie Cable, Lead Program Integrity Compliance Specialist, Jennifer Bergmann, Program Integrity Compliance Specialist, Summer Roberts, Program Integrity Compliance Specialist, Vacant, Program Integrity Compliance Specialist, Jamie Larsen, Program Integrity Compliance Specialist, Alyssa Clark, Program Integrity Compliance Specialist, Ross Barnes, Program Integrity Compliance Specialist, Rachel Savage, TPL Tort Recovery Officer, Shawn Ratchford, Security & Compliance Manager, Jackie Thiel, Information Security Analyst, Thomas Somerville (Shane), Information Security Analyst, Michael De La Torre, Lead Computer Application Engineer, Marty Wangen, Computer Application Engineer, Great Falls, Vacant, Computer Application Engineer, Shane Echo, Computer Application Engineer, Sasha Harlow, Computer Application Engineer, John Monday, Computer Application Engineer, Paul Nagel, Training Development Specialist, Erica Graham, Network Systems Analyst, Billings, Jesse Hartmann, Network Systems Analyst, Kathleen Kershaw, Network Systems Analyst, Scott Pomajevich, Computer Security Engineer, Sherry Mitschke, Computer Security Engineer, Jarrod Lindseth, Computer Security Engineer, Casey McMahon, Computer Security Specialist, Sheldon Kaldor, Computer Security Specialist, Joseph Hudson, Computer Support Specialist, Robert Markovich, Computer Support Specialist, Shawn Schreiber, STATE MOTTO: ORO Y PLATA (GOLD AND SILVER), Public Health and Human Services, Department of. murders in newcastle upon tyne 1980s, hydrogen peroxide poison ivy, mildred marguerite spence, Person 's risk for heart attack and heart disease Or heart attack and heart disease obj % it best! 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