N.H. Admin. Code § He-P 2503.01

Current through Register No. 50, December 12, 2024

Section He-P 2503.01 - Application Procedure

The applicant shall submit the following as part of the application process, before any financial assistance is provided:

(a) A CIP application including:

(1) The applicant's dated signature, authorizing the release of information and allowing the department to communicate with health care providers; and

(2) The applicant's dated signature, authorizing the department to collect the applicant's medical records;

(b) A signed statement verifying that the income information provided on the application in (a) above is correct; and

(c) Written documentation justifying the income information provided on the application form are correct, including:

(1) The most recent income tax return of all those persons whose income is counted in determining family income;

(2) The applicant's 4 most recent consecutive paycheck stubs, if tax returns are unavailable; or

(3) A letter from the applicant's most recent employer indicating present gross salary or wages and expected changes during the next 12 months.

N.H. Admin. Code § He-P 2503.01

#2484, eff 9-26-83; ss by #4167, eff 11-6-86; ss by #4638, eff 6-26-89, EXPIRED: 6-26-95

New. #8864, eff 4-13-07