SR 07-27 Dated 11/07 |
STATE OF NEW HAMPSHIRE
INTER-DEPARTMENT COMMUNICATION
DFA SIGNATURE DATE: |
October 11, 2007 |
FROM: |
OFFICE OF THE DIRECTOR, DFA Terry R Smith |
AT (OFFICE): |
Division of Family Assistance |
TO: |
DFA Supervisors District Office Managers of Operations
|
SUBJECT: |
Relocation of New Hampshire Healthy Kids Corporation Division of Family Assistance District Office #78; Revised Form 125, Transfer of Client Records, Form 800P, Application for NH Healthy Kids Medical Insurance or Medical Coverage for Pregnant Women, Form 800PEN, Notice of Presumptive Eligibility Decision for Medical Coverage for Children and Pregnant Women, and Form 800PR, Review For Continued Eligibility For NH Healthy Kids Medical Insurance and Medical Coverage for Pregnant Women, and Their Associated Instructions |
EFFECTIVE DATE: |
November 5, 2007 |
SUMMARY
This SR releases the following forms revisions resulting from the relocation of New Hampshire Healthy Kids Corporation Division of Family Assistance District Office #78, from 25 Hall St Concord, NH, to 1 Pillsbury St, 3rd Floor, Concord, NH:
§ Form 125, Transfer of Client Records, and its associated instructions;
§ Form 800P, Application for NH Healthy Kids Medical Insurance or Medical Coverage for Pregnant Women, and its associated instructions;
§ Form 800PEN, Notice of Presumptive Eligibility Decision for Medical Coverage for Children and Pregnant Women, and its associated instructions; and
§ Form 800PR, Review For Continued Eligibility For NH Healthy Kids Medical Insurance and Medical Coverage for Pregnant Women, and its associated instructions.
POLICY
Effective November 5, 2007, the new address for the NH Healthy Kids District Office #78 will be:
New Hampshire Healthy Kids Corporation Division of Family Assistance
1 Pillsbury St, 3rd Floor
Concord, NH 03301-3556
The following forms were updated accordingly:
§ Form 125, Transfer of Client Records, and its associated instructions;
§ Form 800P, Application for NH Healthy Kids Medical Insurance or Medical Coverage for Pregnant Women, and its associated instructions;
§ Form 800PEN, Notice of Presumptive Eligibility Decision for Medical Coverage for Children and Pregnant Women, and its associated instructions; and
§ Form 800PR, Review For Continued Eligibility For NH Healthy Kids Medical Insurance and Medical Coverage for Pregnant Women, and its associated instructions.
NEW HEIGHTS SYSTEMS PROCEDURES AND IMPLEMENTATION
Effective October 29, 2007, New HEIGHTS will begin using the new address on all correspondence (NODS, letters, etc.) generated for the NH Healthy Kids District Office #78.
POLICY MANUAL REVISIONS
Revised Family Assistance Manual Topics
Section 131.01 Presumptive Eligibility
IMPLEMENTATION
Current versions of both the Form 800P, Form 800PEN, and Form 800PR may be used until the supply is exhausted. The new versions of the forms will be printed when the current supply is exhausted.
Detach the electronic version of the Form 125 released with this SR into the District Office templates folder on the shared drive, and begin using the new version November 4, 2007.
CLIENT NOTIFICATION
A one-time mailing to notify clients scheduled for a November eligibility review of the new mailing address occurred on October 12, 2007 – October 15, 2007. No other special notification is planned. The letter is attached for reference.
TRAINING
No training is planned or needed.
FORMS MANUAL POSTING INSTRUCTIONS
Remove and Destroy |
Insert |
Forms Manual
Form 125, Transfer of Client Records, SR 00-50/November, 2000 1 sheet |
Form 125, Transfer of Client Records, SR 07-27/November, 2007 1 sheet |
Form 125(i), Instructions for Form Form 125, SR 00-50/November, 2000 1 sheet |
Form 125(i), Instructions for Form 125, SR 07-27/November, 2007 1 sheet |
Form 800P, Application for NH Healthy Kids Medical Insurance or Medical Coverage for Pregnant Women, SR 06-16/December, 2006 4 sheets* |
Form 800P, Application for NH Healthy Kids Medical Insurance or Medical Coverage for Pregnant Women, SR 07-27/November, 2007 4 sheets* |
Form 800P(i), Instructions for Form 800P, SR 06-16/December, 2006 1 sheet |
Form 800P(i), Instructions for Form 800P, SR 07-27/November, 2007 1 sheet |
Form 800PEN, Notice of Presumptive Eligibility Decision for Medical Coverage for Children and Pregnant Women SR 04-11/May, 2004 1 sheet |
Form 800PEN, Notice of Presumptive Eligibility Decision for Medical Coverage for Children and Pregnant Women SR 07-27/November, 2007 1 sheet |
Form 800PEN(i), Instructions for Form 800PEN, SR 04-11/May, 2004 1 sheet |
Form 800PEN(i), Instructions for Form 800PEN, SR 07-27/November, 2007 1 sheet |
Form 800PR, Review For Continued Eligibility For NH Healthy Kids Medical Insurance and Medical Coverage for Pregnant Women, SR 06-16/December, 2006 4 sheets* |
Form 800PR, Review For Continued Eligibility For NH Healthy Kids Medical Insurance and Medical Coverage for Pregnant Women, SR 07-27/November, 2007 4 sheets* |
Form 800PR(i), Instructions for Form 800PR, SR 06-16/December, 2006 1 sheet |
Form 800PR(i), Instructions for Form 800PR, SR 07-27/November, 2007 1 sheet |
*Due to the software used to create the Form 800P and Form 800PR, the forms cannot be attached to this SR but will be provided to District Offices in hardcopy version, once the new version is printed. |
DISPOSITION
This SR may be destroyed or deleted after its contents have been noted and the revised manual topics released by this SR have been posted to the On-line manuals.
DISTRIBUTION
This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR, and revised On-Line Manuals, will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at http://www.dhhs.nh.gov/DHHS/DFA/LIBRARY, effective October 29, 2007.
This SR, and printed pages with posting instructions, will be distributed under separate cover to all hard copy holders of the Forms Manual.
DFA/JBV:s