SR 21-07 Dated 07/21 |
STATE OF NEW HAMPSHIRE
DEPARTMENT OF HEALTH & HUMAN SERVICES – DIVISION OF ECONOMIC AND HOUSING STABILITY
Bureau of FAMILY ASSISTANCE (BFA)
INTER-DEPARTMENT COMMUNICATION
FROM: |
OFFICE OF THE ADMINISTRATOR IV, BFA Debra E. Sorli |
BFA SIGNATURE DATE: |
June 30, 2021 |
AT (OFFICE): |
Bureau of Family Assistance |
TO: |
All BFA Staff |
SUBJECT: |
Updated BFA Form 777, NH EASY Provider Enrollment |
EFFECTIVE DATE: |
June 30, 2021 |
SUMMARY
This SR releases revisions to the DFA Form 777, NH EASY Provider Enrollment Form, as well as the DFA Form 777(i).
BACKGROUND
Due to the relocation of the New HEIGHTS office, an update to their address on DFA Form 777, NH EASY Provider Enrollment, and associated DFA Form 777(i) is required.
DESCRIPTION OF REVISIONS MADE TO FORMS
Electronic DFA Form 777, NH Easy Provider Enrollment and DFA Form 777(i) have been revised to reflect the change from Division of Family Assistance (DFA) to Bureau of Family Assistance (BFA) by updating the titles and all other instances of Division of Family Assistance and DFA throughout the forms. Additionally, the address for New HEIGHTS has been updated from 7 Eagle Square, Suite 301, Concord, NH 03301 to the new office location at 64 South St, Concord, NH 03301.
IMPLEMENTATION
The new versions of BFA Form 777 and 777(i) will be electronically transmitted with the release of this SR, posted in the BFA Forms Folder on the N:\ Drive for Department staff, and available under the Forms section of the NH EASY Gateway to Services website. Revised forms will be used immediately following release of this SR.
CLIENT NOTIFICATION
No special client notification is planned or needed.
TRAINING
No special training is planned or needed.
FORMS POSTING INSTRUCTIONS
Remove and Destroy |
Insert / Replace
|
DFA Form 777, NH EASY Provider Enrollment Form, DFA SR 15-11/October, 2015 1 back-to-back sheet |
BFA Form 777, NH EASY Provider Enrollment Form, BFA SR 21-07/June, 2021 1 back-to-back sheet |
DFA Form 777(i), DFA SR 15-11/October, 2015 1 back-to-back sheet |
BFA Form 777(i), BFA SR 21-07/June, 2021 1 back-to-back sheet |
DISPOSITION
This SR may be destroyed or deleted after its contents have been noted and the revised forms released by this SR have been posted.
DISTRIBUTION
This SR will be distributed according to the electronic distribution list for BFA policy releases. This SR will be available for agency staff in the On-Line Manual Library accessible August 1, 2021, and for public access under the Bureau of Family Assistance Publications section of the NH DHHS website.
BFA/JLR:s