STATE OF NEW HAMPSHIRE

DEPARTMENT OF HEALTH & HUMAN SERVICES

DIVISION OF PUBLIC HEALTH SERVICES
NH RYAN WHITE CARE PROGRAM
(603)271-4502 (800)852-3345 x4502
(603)271-4934 fax

NH CARE APPLICATION
Date of application: _______________
Initial Application

Renewal Application

Last Name

First

M.I.

Street Address

DOB

City/Town

State

Zip

Mailing Address (if different than above)

Home phone

Cell phone

Other phone

E-mail address
Social Security #

Birth Country

Male

Can we leave a detailed message on your answering machine?

Yes

If no, who can we contact? Name:

Phone: (

Can we mail information to the above address?

Yes

No

Female

No
)

Relationship:

OK to receive emails?

Yes

No

If no, what address can we mail to?

Do you work with a case manager at an AIDS Service Organization or doctors office?
Case manager:

Organization:

Primary physician:

Phone: (

Phone: (

Yes

No

City/Town:
Specialty care physician:
City/Town:
Pharmacy:

Phone: (

Street:

City:

Housing status:

permanent

temporary

First three (3) letters of your mothers first name:

Mail Order:
Phone: (

homeless

institution

(needed to create your confidential unique ID code)

pg. 1 of 5

Transgender

INCOME INFORMATION
Number of persons in your household?
Source(s) of income

Weekly

Monthly

Yearly

Wages

Other (explain):

Other (explain):

Totals:

Proof of income (most recent)

Pay Stub

Social security or unemployment check

Federal Income Tax

Bank Statement

Employer letter stating wages

Other:

Note: If your income exceeds 400% of the federal poverty level, proof of medical expenses can be submitted to spend down and
qualify you for the program, ask for details.
MEDICAID (applicants are required to apply to Medicaid once per year)
Have you applied for Medicaid?
Approved:

Yes

No

Yes

No

Date applied:

Pending

ID #

MEDICARE PART A and B

Part A:

Yes

No

Unknown

Start Date:

Part B:

Yes

No

Unknown

Start Date:

No

Unknown

Start Date:

MEDICARE PART D
Part D:

Yes

Plan name:

ID #

INSURANCE (you may qualify for assistance with insurance premiums or cobra continuation, ask for details)
Are you covered by medical health plan?

Yes

No

Is this a COBRA plan?

Plan name:

Yes

No

ID#

DEMOGRAPHICS (information is kept confidential)

1. What language do you speak most often?

English

2. Which of the following best describes your race?

Native Hawaiian/Pacific Islander

Spanish

White

Other: ______________________

Black or African American

American Indian/Alaskan Native

3. Which of the following best describes your ethnicity?

French

Hispanic/Latino

pg. 2 of 5

Asian

More than one race

Non-Hispanic/Latino

Rev. 8-15

By signing below, I certify that I have read, understand, and comply with the Non-Discrimination Notice, Client Certification,
Grievance Procedure, and Review of Records.
Non-Discrimination Notice
The State of New Hampshire, Department of Health and Human Services, does not discriminate against people because of their age, sex,
race, creed, color, marital status, familial status, physical or mental disability, national origin, sexual orientation or political affiliation or belief.
There will be no discrimination in accepting or providing services, or the admission or access to, or treatment or employment in, any of the
Departments programs or activities. The Controller is responsible for coordinating the civil rights compliance efforts of the Department,
component offices and divisions to follow state and federal rules against discrimination. For more information, or to learn h ow to make a
discrimination complaint, contact the Controller at 129 Pleasant Street, Concord, New Hampshire 03301; or you may telephone (603) 2714963 (voice) or the TDD Access number: 1-800-735-2964. The New Hampshire Department of Health and Human Services is subject to Title
VI of the Civil Rights Act of 1964 (42 U.S.C., Section 2000d et. seq.); Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C.,
Section 794); Title IX of the Education Amendments of 1972 (20 U.S.C., Section 1681); the Age Discrimination Act of 1975 (42 U.S.C., Section
6101 et. seq.); NH RSA 354-A; and certain federal block grant statutes, including, but not limited to 42 U.S.C., Sections 300x-7, and 708, or
any other provision through which the Department receives federal financial participation in its programs. These laws prohibit discrimination
on the basis of age, sex, race, creed, color, marital status, familial status, physical or mental disability, national origin, sexual orientation or
political affiliation or belief in federally-assisted and state funded activities. The U.S. Department of Health and Human Services regulations
under Title VI, Section 504, Title IX and the Age Discrimination Act are found at 45 C.F.R., Parts 80, 84, 86 and 91, respectively. The New
Hampshire Department of Health and Human Services is further subject to the Americans with Disabilities Act of 1990 (42 U.S.C., Section
12101, et. seq.) and its implementing regulations at 28 C.F.R., Part 35.

Client Certification
1. I hereby declare that my financial statements are correct and true to the best of my knowledge. I realize that the NH CARE Program
receives its funds from the State of New Hampshire and that any intentional misrepresentation may result in legal action against me on
the basis of state or federal laws. Furthermore, I understand that I will be denied participation if I withhold information, provide inaccurate
information, or refuse to provide all of the necessary information. I agree to notify the NH CARE Program within 30-days of any change in
my name, address, eligibility, financial, insurance status or household size, and to provide evidence of income and medical expenses,
Medicaid or Medicare status and/or health insurance policy. I agree to return any refunds sent to me but owed to the NH CARE Program.
I fully agree to comply with the conditions stated above.
2. In order to be considered for participation in the NH CARE Program, I hereby authorize my physician or his/her representative to release
information requested by the NH CARE Program relative to the content of my medical record. I understand that this information will be
maintained under strict conditions of confidentiality and that my identity will not be revealed to any persons outside of the Dept. of Health
and Human Services. All information given to the NH CARE Program is strictly confidential and will not be released to any other parties
unless allowed under the law.
3. I hereby authorize the staff of the NH CARE Program to communicate with and release information, including my diagnosis, to appropriate
physicians and other health care professionals including my pharmacist, case manager and other treatment providers, to ensure the best
possible planning and delivery of services on my behalf. If I am applying for insurance continuation, I authorize the NH CARE Program to
speak with my employer and/or insurance or COBRA provider regarding my status and may contact any third party payers/administrators
to ensure coverage and resolve billing issues. This release is valid for one (1) year from signature unless revoked by me in writing.

Grievance Procedure
1. If you are dissatisfied with eligibility determination, you may request, within 30 days of the date of the NH CARE Programs notification
letter, an informal case review conference.
2. The NH CARE Program shall notify you within 14 days after the case review conference whether the NH CARE Program concurs,
modifies, or revokes the determination.
3. If you or your guardian is dissatisfied with the result of the case review, a request may be made within 30 days of notification of said
result, an adjudicative proceeding which shall be held in accordance with RSA 541-A.
4. You must contact the NH CARE Program Manager if youre denied eligibility. If then, you are still dissatisfied with the response, contact
the Section Director at 800-852-3345 x0290.
5. You may contact the Office of Ombudsman at any point in the process for neutral resolution of your complaint at 800-852-3345 ext. 6941.

Review of Records
I hereby authorize the NH Dept. Health and Human Services and/or the City of Boston/Trustees of Health and Hospitals, which provides
funding for this program, access to my record for the purpose of review for monitoring purposes only, to include: my name, HIV status, related
diagnoses, substance abuse treatment, medical care/treatment, financial circumstances, living arrangements, and other information as
requested. I understand the review is visual only and no records shall be copied, recorded, or removed. I understand I am not required by law
to consent to release this information, but do so willingly and voluntarily, and that I may revoke consent at anytime in writing, except to the
extent action has been taken in reliance of my consent. This authorization will have duration of two (2) years from date of signature.
________________________________________________________________________________________________________________
Applicant/Guardian Signature

Date

________________________________________________________________________________________________________________
Witness Signature

Date
pg. 1 of 8

Physicians Release of Information

I hereby authorize my physician or physicians representative, to release information requested by the NH CARE
Program, relative to the content of my medical record. I understand that this information will be maintained under strict
confidentiality, will not be revealed to persons outside the NH Department of Health and Human Services, and will be
used solely for my benefit. This release is valid for one (1) year from date of signature unless revoked by me in writing.
_______________________________________________________________________________________________________
Applicant/Guardian Signature
Date
_______________________________________________________________________________________________________
Printed Name
_______________________________________________________________________________________________________
Witness Signature
Date

Physicians Information
_______________________________________________________________________________________________________
Physician Name
_______________________________________________________________________________________________________
Hospital/Clinic Name
City/Town
_______________________________________________________________________________________________________
Phone #
Fax # (optional)

pg. 4 of 5

Rev. 8-15

APPLICANT CHECKLIST
(please keep for your records)

Applications are good for six months. At the end of six months you will need to submit a new
application. If your enrollment expires, you will not be eligible for services.

Applicants are required to apply to Medicaid one time per year. Your application can be denied if
this requirement is not met.

The Patient Medical Information (pg. 6-7), must be completed by a physician. It can be faxed
to the NH CARE Program at 603-271-4934.

Attach a copy of your insurance or medicare card.

Attach a copy of your pay stub OR social security check OR unemployment check OR federal
income tax return.

If you have no income, your case manager will need to write a letter stating you have no income.
Mail my application to the CARE Program at: DHHS- NH CARE Program
29 Hazen Drive
Concord NH 03301

*******
NH CARE Program
8:30 4:30
Monday thru Friday
Main Office: (603) 271-4502 (800) 852-3345 x4502
CARE Manager: (603) 271-3958 (800) 852-3345 x3958

pg. 5 of 5

Rev. 8-15