New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-P - Former Division of Public Health Services
Chapter He-P 2500 - CATASTROPHIC ILLNESS PROGRAM
Part He-P 2503 - APPLICATION PROCEDURE
Section He-P 2503.01 - Application Procedure
Universal Citation: NH Admin Rules He-P 2503.01
Current through Register No. 40, October 3, 2024
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.
#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
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