SR 15-18 Dated 04/15

 

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

 

FROM OFFICE OF THE DIRECTOR, DFA:

Terry R. Smith

DFA SIGNATURE DATE:

April 8, 2015

AT (OFFICE):

Division of Family Assistance

TO:

District Office Supervisors

 

SUBJECT:

Elimination of the Requirement of Providing the DDU Form 900, Authorization for Release of Protected Health Information, to Assist in the Disability Determination Unit (DDU) Aid to the Needy Blind Medical Eligibility Determination, Revised DDU Form 901, Report of Eye Examination, and Its Associated Instructions

EFFECTIVE DATE:

April 10, 2015

 

 

SUMMARY

 

This SR releases the elimination of the requirement of providing the Disability Determination Unit (DDU) Form 900, Authorization for Release of Protected Health Information, to assist in the DDU’s medical eligibility determination for Aid to the Needy Blind (ANB) cash and medical assistance. The Adult Assistance Manual (AAM), Medical Assistance Manual (MAM), and DDU Form 901, Report of Eye Examination, and its associated instructions, were updated accordingly.

 

FORMER POLICY

NEW POLICY

For ANB medical determinations, Family Services Specialists (FSS) were required to send the following forms to DDU for the ANB medical eligibility determination process as well as any other documentation that may bear upon the medical eligibility decision:

• DDU Form 901, Report of Eye Examination, completed by a licensed ophthalmologist or optometrist; and

• a separate DDU Form 900, Authorization for Release of Protected Health Information, for each ophthalmologist or optometrist accessed by the client to verify blindness.

For ANB medical eligibility determinations, only the DDU Form 901 needs to be completed and returned to the DDU along with any other documentation that may bear upon the medical eligibility decision.

 

POLICY

 

For ANB medical eligibility determinations, only the DDU Form 901, Report of Eye Examination, needs to be completed and returned to the DDU along with any other documentation that may bear upon the medical eligibility decision. DDU Form 900, Authorization for Release of Protected Health Information, is no longer also needed.

 

DESCRIPTION OF REVISIONS MADE TO FORMS

 

DDU Form 901, Report of Eye Examination, was revised as follows:

 

·      The information at the top of the form requesting the FSS name, District Office, and Application date was removed from the form. This information was for DHHS/DDU staff use only, and the data is accessible to all staff in New HEIGHTS.

·      The Authorization for Release of Medical Information section of the form was greatly expanded to incorporate federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) patient confidentiality and security protection requirements. These changes were reviewed and approved by Jean Bergman, the DHHS Privacy Officer.

·      Minor formatting changes were made to add check boxes where check boxes were appropriate, and to request a few more details about the ophthalmologist or optometrist in the event DDU staff need to contact the health care provider.

·      DDU Form 901 will now be offered in an electronic version only, available to all DHHS on the Lotus Notes Family Services Database. It will no longer be printed or stored in the DHHS warehouse.

 

The instructions were updated accordingly. The updated version of this form is available for immediate use, for Department staff only, on the Lotus Notes Family Services Database.

 

POLICY MANUAL REVISIONS

 

Revised Adult Assistance Manual Topic

 

Section 207.01 Verification: ANB

 

Revised Medical Assistance Manual Topic

 

Section 207.01 Verification: ANB

 

IMPLEMENTATION

 

The policy released in this SR is effective April 10, 2015. The updated version of this form is available for immediate staff use on the Lotus Notes Family Services Database.

 

CLIENT NOTIFICATION

 

No special client notification is planned or needed.

 

TRAINING

 

No special training is planned or needed.

 

FORMS MANUAL POSTING INSTRUCTIONS

 

Remove and Destroy

Insert

 

Forms Manual

 

 

 

Office of Medical Services (OMS)/Division of Welfare Form 901, Report of Eye Examination, OMS SR 97-29/March, 2004

1 back-to-back sheet

DDU Form 901, Report of Eye Examination,

DFA SR 15-18/April, 2015

1 back-to-back sheet (electronic form)

OMS Form 901(i), Instructions for Form 901,

OMS SR 82-101/July, 1982

1 back-to-back sheet

DDU Form 901(i), Instructions for Form 901,

DFA SR 15-18/April, 2015

1 back-to-back sheet

 

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 www.dhhs.nh.gov/DFA/publications.htm, effective April 27, 2015. Additionally, this SR, and printed pages with posting instructions, will be distributed under separate cover to all internal hard copy holders of the Adult Assistance, Forms, and Medical Assistance Manuals.

 

DFA/JBV:s