Box 181, Concord, NH 03301 DFA SR 11-43 (A) REIMBURSEMENT AGREEMENT AND ACKNOWLEDGMENT Applicant Name: Spouse: Name: (Please print) (Please print) . ==c a41j01P F!+dPP;)\1iU2hSB_On)/JTa1"BL$CJG ZSv ,M0_9*mmMHd6uCm+jE":E@HVQP(U * jr-pKVI$HV $$Qm%H+&58O^AS,As*F%$U)jDJ":% *%mJZ%:5mJnc(O2 BFA SR 19-29 This institution is an equal opportunity provider. ' .GIr!~)H#H?`6h=T4hB \%,dMRU:N 3 <> _ ` By law, the EAP staff must notify appropriate agencies of: We are committed to the principle that any information or material we receive, other than that required by law to be reported to authorities will not be communicated to anyone without your permission. 2 0 obj There are so many options to choose from, so knowing what you want to get out of your scanner is key. When calcified plaques occur in the coronary arteries, the condition is called coronary artery disease, or CAD, which is a leading cause of heart attack and death. <>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 7/2OPcMTvsoDZ)jYJle^VzYdJ]UyU:U%W_U.JQubFMPs0. RRH_T|/yEpg0VtPY>'k] Concord, NH 03301 The following tips can help you fill out NH DHHS DFA 756 quickly and easily: Open the document in the feature-rich online editing tool by clicking Get form. New York. %PDF-1.6 % u3O/KeI^#[Fo/d(\UK5z p?sxF,Czx%[_w44q^TVz8udw"+J>wSw~A('e+S55 Diving into the digital world and looking at scanners can prove to be a hassle. }yB%YFY'j/QRaa O^`"=g/*nxrzdz-TE;BVXG+hi`nW'IbcAf~"KUtGd*tZF~r <>>> <> 1207 0 obj <>stream %PDF-1.5 4 0 obj <> H_K~Dn~"v6 j_O9V) When starting off on your search for a scanner, it is important to know the difference between centralized scanning and decentralized scanning. endobj 1193 0 obj <>/Filter/FlateDecode/ID[<8C2304EE3BAA2B4BA51333F619C6E237><6A45965FEF636F41A7C4DDF41080F3DD>]/Index[1170 38]/Info 1169 0 R/Length 111/Prev 271610/Root 1171 0 R/Size 1208/Type/XRef/W[1 3 1]>>stream NH Department of Health and Human Services (DHHS) DFA Form 770 Estate Recoveries Unit/Division of Family Assistance (DFA) 11/11 rev 1/15 rev2 9/16 Return to: Centralized Scanning Unit (CSU), P.O. NH Department of Health and Human Services (DHHS) BFA Form 474 Bureau of Family Assistance (BFA) 10/19 Return this form to: Centralized Scanning Unit (CSU), P.O. Amazon Fulfillment Center-Djz4. For information on available treatment in NH, go to www.covid19.nh.gov/resources/treatment-resources, Or look for an answer in our Frequently Asked Questions. | gZ&)wI,H&-`~YbZ'G~ o+XwH Y_\Ljs. 1 0 obj endobj stream However, DHHS will not share your health information. <>>> YsC5 d!GPg$Pk$PkPg$Pk$PkPg$PNT U(;te1dbHO/'Gm]i;_!1W}Lz{=\cWTJ'-SCi]Vi]DGx*X#65:kXa2sn Q=yG*2qtt#BShE EvQvQeIO0p'xmYb=4nll%PkEP2$mIf;dmYicC4begYUQ(ZU@*JV##b`,WE*zWdX;]^/J9'[5nr7Fu$6vR^]hst .tf1=s.7$[\%l\7VJ). Go to the Locations & Facilities page. endobj These scanning can range from personal desktop scanners to production scanners. 36T_9?=)^wU(Z^ T_'NlXZ\^VUM=xO]R":ug5z/%91x^W[?Jhc Q !, Q0u`J)Ea@Dp1 iBqdEuzt{J~T6 k1F6Qbv*jyGP9H)Te+fSCKiP}MDe_|PC}`XH'[C4k+^\^0i3t9P3Y4 syf`^LGC gd8!r;WTc,7:!(OWf@6 !d^ F%="!4gF` guiHO*U66vC7(.EcSMx>Z+e7L"0aQ % q^.I7khxGF:F@u~V(l^yZVo h|-('- endobj ]G7U2{|^xBhqgL]a|xX"ZDt`1NH PD+kqeXY?0j[cj3@2k4h} rc6f}'WTx`s1]tt\EY_3kH@ip0tKtE=iP ;KN*IF6|,~C,(m l\fq l1I1=Ex>m 2lhY H> E?K-k. %PDF-1.5 The final score will be used by your doctor to assess your heart attack risk and recommend treatment and lifestyle changes when needed. Centralized Intake Unit 111 N Last Chance Gulch, Helena, MT 59601-6282 PO Box 8005, Helena, MT 59604-8005. stream 111 North Sanders Helena, MT 59601-4520 PO Box 4210 Helena, MT 59604-4210, 1400 Broadway, Rm C314, Helena, MT 59601-5231, Asthma and Diabetes Prevention and Control Programs, Nutritional and Physical Activity Program, 1400 Broadway, Room C202 Helena, MT 59601-5231 TOP, 1400 Broadway, Room B102 Helena, MT 59620, 1400 Broadway, Room C216 Helena, MT 69601-5231, 1400 Broadway, Room C216 Helena, MT 59601, Program Planning Unit 111 N Last Chance Gulch, Helena, MT 59601-6282 PO Box 8005, Helena, MT 59604-8005 TOP, Centralized Intake Unit 111 N Last Chance Gulch, Helena, MT 59601-6282 PO Box 8005, Helena, MT 59604-8005, 1625 11th Ave, Helena MT 59601 PO Box 4210, Helena MT 59620, 1625 11th Ave, Helena MT 59601 PO Box 4210, Helena MT 59620 TOP, Food Distribution/Commodity Warehouse Program 1400 Carter Drive, Helena, MT 59601-6400 PO Box 202956, Helena MT 59620-2956 TOP, Energy & Community Services Program (LIEAP & Weatherization) 1400 Carter Drive, Helena, MT 59601-6400 PO Box 202956, Helena, MT 59620-2956 TOP, Medicaid & Healthy Montana Kids Drug Rebate Program, 1400 Broadway, Room A104 Helena, MT 59601-5231, Audit Bureau 2401 Colonial Dr, 3rd Floor Helena, MT 59601-4909, Administrative Support Supervisor,Afrah Al Asadi, Administrative Assistant,Andrew Erickson, 1100 N. Last Chance Gulch, 2 nd Floor, Helena, MT 59601 TOP, State Information Technology Services Division PO Box 200113 Helena, MT 59620-0113 CONTACT US, STD DIS Program Specialist, Miranda Reddig, U.S. BUREAU OF LABOR STATISTICS FOR MONTANA, MONTANA OFFICE OF TOURISM AND BUSINESS DEVELOPMENT, MONTANA HISTORICAL SOCIETY RESEARCH CENTER, Behavioral Health and Developmental Disabilities, Office of Inspector General (formerly Quality Assurance), State Information Technology Services Division, Economic Security Services Executive Director, Erica Johnston, Medicaid and Health ServicesExecutive Director, Mike Randol, Medicaid and CHIP State Plan Amendment and Waiver Coor., Mary Eve Kulawik, Strategic Planning, Research andAnalysis, Eric Higginbotham, Operations Revenue Forecasting Specialist, Jamie Bartole, Office of Inspector General, Michelle Truax (Interim), State Medical Officer, Dr. Maggie Cook-Shimanek, Office of Health and Human Services Innovation, CIO, Marie Matthews, Legislative and Regulatory Affairs, Brenton Craggs, Communications Specialist, Herbert Council, Program Analyst/Technical Writer, Megan Grotzke, Faith and Community Based Services, Tracy Moseman, American Indian Health Director, Stephanie Iron Shooter, Chief Human Resources Officer, Karol Anne Davis, Deputy Human Resources Officer, Ciarra Krantz, Civil Rights and EEO Officer , Lloyd Sparks, Senior Human Resource Partner/Employee & Labor Relations, Sarah Green, Senior Human Resource Partner/Facility Liaison, Vacant, Human Resources Office Coordinator, Sam Askin, Risk Management and Safety Officer, Joe McAnally, Occupational Health and Safety Officer, Tawni Jo Carmody, Deputy Chief Legal Counsel, Chad G. Parker, Attorney, HIPAA Program Officer, Theran Fries, Office Manager / Administrative Rule Specialist, Valerie St. Clair, Administrative Rule Specialist, Kassie Thompson, Administrative Legal Assistant, Bailey Yuhas, Medicaid Systems Operations Manager, Shellie McCann, State MedicalDirector, Dr. Maggie Cook-Shimanek, MD, Local & Tribal Support Coordinator, Kerry Pride, DVM, System Improvement Coordinator, Terry Ray, Public Health Accreditation Coordinator, Vacant, Workforce Development Coordinator, Neva Loney, Performance Management and Information Systems Coordinator, Marilyn Trevino, State Refugee Coordinator, Kathe Quittenton, Epidemiology Program Manager, Heather Zimmerman, Office Manager/Financial Specialist, Jodee Prevel, Disability Health Education Specialist, Mackenzie Jones, Office Manager/Financial Specialist, Susan Day, Administrative Specialist, Carolyn Linden, Determinates of Health Program Manager, Margaret Mullins, Secondary Prevention Specialist, Mike McNamara, Quality Improvement Coordinator, Callan Brick, Asthma Control Program Manager, BJ Biskupiak, EMS Licensing and PI Specialist, Francine Janik, Cardiac Ready Program Manager, Janet Trethewey, Community Integrated Health Program Specialist, Kelly Little, Trauma System Manager, Alyssa Johnson, RN, BSN, Violent Death Registry Program Manager, William "Buck" Herron, Injury Prevention Coordinator, Maureen Ward, Health Education Specialist, Alivia Winters, Administrative Support/Licensing, Sandra Tirrell, Body Art/Trailer Court Camp Grounds/ Cottage Food/ Farmers Markets, Mark Hall, Wholesale Mfg. Main DHHS Switchboard: (402) 471-3121. Employees and departments participating in the Employee Assistance Program may be concerned about the matter of confidentiality. <> ndfJXN)Z4;B@Jo$Fzp"mfPB %s2!0>|h/KD0.%51~G3|*)L%{gbEpt"*dOhLiF:)-|yGg|]nOI _w[FV__@j#76^_><1Lw =K|4[&W,%?eRo`Z,/^o_&O]0M,0aQvQB>%.|tbX-8)`EMvep !Uf*&VW.=w H}T.MuJZXDVcD1}L-Rl(B)Es:TXJzAka0* jnaR xy:ia+M']Q-M~mFVQ{21~?~&yx"2f DHHS has a wide range of programs located in offices across the state. 3 0 obj Download the form you want from the largest collection of templates. 4 0 obj V[$&Bb5F$|zt (5N' PgNrj[Wu`F(0^v?Tw|;:y^/_"/a2ke&r?6mBin@\fGt_b_=P6+Jr@%763{@]F0n) mr P%n9mMj+W@t--2{]s$pHqf8.p2f0mlUM`]RUziC7x(;Ls@*VS %PDF-1.5 New Hampshire Employment Verification Letter for Bank With more than 85,000 state-specific editable templates, US Legal Forms guarantees you will find the exact document you need. When should you upgrade your printer or copier? 3 0 obj Q\z15b>='w23\K|&6`.lo]2VdITi2-'\NOJL6'o3?nZ. <> family history of heart disease or heart attack. 2 0 obj If you test positive for COVID-19 and have symptoms, antiviral medication can help! 0 We are proud to offer this exam for the everyday price of $79. An Employee Assistance Program (EAP) is a program that can help with everyday issues to traumatic events. Tel: +1 310 634 0130. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> The CIT & Authorization mission is to promote and protect public health by: Managing Centralized Intern Training for new agents of the state to become authorized to enforce state sanitation laws and rules. department of health and human services division of economic and housing stability bureau of employment supports 129 pleasant street, concord, nh 03301-3857 603-271-9474 fax: 603-335-5993 tdd access: 1-800-735-2964 www.dhhs.nh.gov participant expectations & commitment name: rid#: (for internal use only). NH Department of Health and Human Services (DHHS) BFA Form 765 Bureau of Family Assistance (BFA) 06/15 rev 2/19 DFA SR 15-15 Return to: Centralized Scanning Unit (CSU), P.O. Suicide Prevention: 988. collector: ethan davio phone: 603-476-2348 x TF3e>,YecW=f~+J}VQiIvCYA~,IE`z1Fb2aw(G#&Jv-4m6n} `|UzT4MPjJ5"3t* hbbd```b``6@$2,^qA$k*X6L`Y00V/ "OkAd>-`@D% E Box 181, Concord, NH 03301 (1YC) Application for Emergency Assistance Name Phone Number Address Intake Procedure (1) Children and young adults in families who are already receiving SNAP do not need to apply, the benefits will be loaded onto their LINK/EBT card automatically, (2) Apply online at ABE.illinois.gov, or fill out the paper application by downloading it from the IDHS website and emailing the completed form to DHS.FCS.PEBT@illinois.gov, (3) Completed application forms can also . Medicaid Assistance: (855) 632-7633. more.. iServe Nebraska . endobj 2 0 obj The EAP liberally defines family member to include significant people in the lives of employees. \@ 9x i~u Some insurance companies may cover the test as long as you have a doctors referral and preauthorization. endobj NH Department of Health & Human Services (DHHS) DDU Form 177 Bureau of Family Assistance (BFA) - Disability Determination Unit (DDU) rev 12/22 Page: 1 of 9 . endobj In addition to specific services directed to individuals, EAP provides consultation services to managers and supervisors effectively addressing group problems or group-focused improvements. New Hampshire Employment Verification Letter for Social Security If finding legal forms online looks like a problem, use US Legal Forms. 6\j|CM:.0q=\ .R.HGHm%eeI.L8]kp]@GO2. h!aYL\>x"LEzX^GR4*{,:B L%H}39S?|J>}^K%i^ _gt3|4\~LN>?_+4OWdT2\&+N;9P%h,@"j{9648oGL ~juV$y$7kX`4#{%?'fvazwr&yy?oc17k Dx/c1l R4]E fAZ>_'9qk5'?:%P2IwU?!0 l$}Mi|0=,Q0t}ns=6\N9J\ u7KGAD]NE6n v-%,#M(T40yJU +SOpG`04TJ*)-L,+o:"[p9aB V=k`0vyiBQn&+Bgj=kXpc>I V94X/50f v@C' LYn.b19 7"Gy4! ] The State of New Hampshire Employee Assistance Program (EAP) is designed to offer assistance to all State employees and their family members. endobj Federal privacy law says that a form like this one must say that if you sign it and your health information gets shared (disclosed), you should know the information may be shared again (re-disclosed). It requires high-volume production scanners, so looking for a scanner with a large document feeder and a high scan speed is key. 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