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Payee Signature Payees must sign and date Form 14. SHADED AREAS ON FORM 14 ARE FOR STATE USE ONLY Mail completed Form 14 and copies of any required documentation to Medicaid Transportation 129 Pleasant Street Thayer Building Concord NH 03301-8575. Keep a copy of the completed Form 14 for your records. When enrollment is complete you will receive a computer-generated document which will provide you with your key name and resource number s.

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NH Medicaid provides payment for health care services ranging from routine preventive medical care for children to institutional care for the elderly and disabled....Covered services can include: physician. hospital. home health. lab. x-ray. rural health clinic. prescription drugs. physical therapy (PT)

Income & Asset Limits for Eligibility 2023 New Hampshire Medicaid Long-Term Care Eligibility for SeniorsType of MedicaidSingleIncome LimitAsset LimitInstitutional / Nursing Home Medicaid$2,742 / month*$2,500Medicaid Waivers / Home and Community Based Services$2,742 / month†$2,5001 more row • 17 Feb 2023

Providers without internet access should ask for alternate arrangements by calling the Medicaid Provider Call Center at (866) 291-1674 or (603) 223-4774.

Use the NH Medicaid Non-Emergency Transportation Program if you need a ride to, or help paying for gasoline to travel to a NH Medicaid covered service.

There are three New Hampshire Medicaid Health Plans to choose from: AmeriHealth Caritas New Hampshire. NH Healthy Families. WellSense Health Plan.

Coverage: This transport is covered by Medicaid as a transportation service and billed directly to the beneficiary's Medicaid health plan or FFS, as outlined in the NH Medicaid Ambulance Provider Manual.

To schedule transportation to provider offices or facilities for services provided directly by NH Healthy Families, call CTS toll-free at 1-877-671-6291.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232