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How to use or fill out NON MEDICAL INFORMATION EVALUATION OF DISABILITY
- Click ‘Get Form’ to open it in the editor.
- Begin with the 'Personal Information' section. Fill in your name, gender, date of birth, and any other names used on medical records. Indicate if you are currently receiving NH Medicaid and provide your household addresses and contact numbers.
- In the 'Ability to Work' section, describe any illnesses or conditions that limit your work ability. Answer questions regarding pain and job-related changes due to these conditions.
- Proceed to 'Vocational Rehabilitation'. 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.
- In the 'Employment' section, list jobs held in the last 15 years, including details like job title, type of business, hours worked, and rate of pay.
- Fill out the 'Mental Health Information' section if applicable, providing details about emotional health issues and services received.
- Finally, complete sections on insurance information and medication. Ensure all fields are filled accurately before submitting.
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