DFA Form 778 2025

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4.7 out of 5

27 votes

The document is a form from the NH Department of Health and Human Services (DHHS) that allows clients to designate an Authorized Representative (AR) to assist them in applying for or managing benefits. It outlines the duties of the AR, the responsibilities of both the client and the AR, and includes sections for signatures and personal information. The form emphasizes the importance of consent and understanding regarding the representation and management of benefits.

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Click ‘Get Form’ to open DFA Form 778 in the editor.
Begin by filling out your personal information in the 'Client’s Information' section, including your printed name, date of birth, and case number.
In the 'Authorized Representative (AR) Duties' section, check off the tasks you want your AR to perform on your behalf.
Provide details about your AR in the 'Authorized Representative Information' section. Include their name, address, and relationship to you.
Ensure both you and your AR sign the form in the designated signature areas, confirming that you understand and agree to the responsibilities outlined.
Review all entered information for accuracy before saving or exporting the completed form for submission.

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See more DFA Form 778 versions

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Versions	Form popularity	Fillable & printable
2023	4.4 Satisfied (58 Votes)
2017	4.7 Satisfied (27 Votes)
2015	3.9 Satisfied (56 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Can I buy out of state health insurance?

Want to buy Marketplace health insurance in another state? As the law exists now, you can only buy health insurance in the state where you maintain your permanent address. Your insurance company may not cover you if you move states and do not report this change in address.

What is the maximum income to qualify for Medicaid NH?

Annual Household Income Limits (before taxes) Household Size*Maximum Income Level (Per Year) 1 $17,131 2 $23,169 3 $29,207 4 $35,2454 more rows

How much is health insurance in NH per month?

Average cost of health insurance by family size in New Hampshire. Health insurance in New Hampshire costs an average of $1,192 per month for a family of four. Health insurance costs more when the plan covers more people. For example, a 40-year-old couple pays an average of $745 per month for health insurance in NH.

How to apply for NH state health insurance?

How to Enroll Apply for NH Medicaid. Visit NH Department of Health and Human Services (DHHS) website . Click the Apply Now link as a new client who is applying for Medical Coverage. Choose a plan. - Call: 1-844-ASK-DHHS (1-844-275-3447) Receive a welcome packet from your plan. Enjoy your new benefits!

How do I contact Medicaid in NH?

Contact the DHHS Customer Service Center toll-free at 1-844-ASK-DHHS (1-844-275-3447) (TDD Relay Access: 1-800-735-2964), Monday through Friday, 8:00 a.m. to 4:00 p.m. ET.

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