N.H. Code Admin. R. He-W 502.03
(a) The applicant, recipient, or the recipient’s family member or authorized representative shall complete the “Authorization for Release of Medical Information” section on Form 901, “Report of Eye Examination” (October 2025) acknowledging the following:
“I understand that the Department of Health and Human Services may use the disclosed information to the extent permitted by state and federal law and may no longer be protected by the HIPAA federal privacy rule (45 CFR Part 164.508(c)).
Specific description of information that may be used/disclosed: Information specifying the history of my visual impairment, physical examination of my eyes, diagnosis, prognosis, and recommendations.
The information will be used/disclosed for the following purposes: Information will be used to determine my eligibility for Aid to the Needy Blind (ANB) cash and medical assistance.
I understand that this authorization is voluntary and that I may refuse to sign this authorization. I further understand that my refusal to sign this authorization may result in a determination that I am not eligible for ANB cash or medical assistance. I understand that I may revoke this authorization at any time by notifying DHHS in writing, to the above-noted address, except to the extent that the authorization has already been used to request information prior to my revocation.
This authorization expires: 12-months from the date this form is signed.”
Source. (See Revision Note at chapter heading He-W 500); ss by #6112, eff 11-4-95; ss by #7132, eff 11-23-99; ss by #9011, eff 10-25-07; ss by #11027, eff 1-26-16; ss by #14416, eff 10-28-2025, EXPIRES 10-28-2036