N.H. Code Admin. R. He-W 890.01 – Reimbursement

(a) The department shall request applicants for medical assistance, including medical assistance provided under medicaid expansion, and their spouses, if any, to provide their signatures indicating that the department has advised them of the requirements of RSA 167:16-a, but a signature on the form shall not be an eligibility requirement.
(b) The form requested in (a) above shall include:
1. (1) The printed name of the applicant;
2. (2) The printed name of the applicant’s spouse, if applicable;
3. (3) The applicant’s street address;
4. (4) The county where the applicant resides;
5. (5) The dated signature of the applicant, and spouse if applicable; and
6. (6) Acknowledgement that the department has advised the applicant of the requirements of RSA 167:16-a.
  Source. #13769, eff 9-28-23
  PARTS He-W 891 through He-W 894 RESERVED