Form 177 2026

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The document is a non-medical evaluation form (DDU Form 177) from the New Hampshire Department of Health and Human Services, specifically for the Medicaid Services Disability Determination Unit. It collects personal information, details about the applicant's disabilities, work history, education, mental health status, and any medical treatments or medications. The information provided will be used to assess the applicant's eligibility for Medicaid disability benefits.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Personal Information' section. Enter your name, date of birth, and any other names used on medical records. Indicate if you are currently receiving NH Medicaid.
In the 'Ability to Work' section, describe any illnesses or conditions that limit your work ability. Answer questions regarding pain and current employment status.
Proceed to the 'Vocational Rehabilitation' section. Indicate if you are receiving services and provide details about past services received.
Complete the 'Education' section by checking the highest grade completed and any special training attended.
List your employment history in the designated area, including job titles, dates worked, and responsibilities.
Fill out the 'Mental Health Information' section if applicable, providing details about any emotional or mental health issues.
Finally, review all sections for completeness before submitting your form to ensure no questions are left unanswered.

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Versions	Form popularity	Fillable & printable
2022	4.4 Satisfied (28 Votes)
2015	4.6 Satisfied (48 Votes)
2007	4 Satisfied (23 Votes)

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Form 177 2026

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