New Hampshire's Financial Assistance to Needy Families (FANF) program can qualify a parent whose physical or mental incapacity substantially reduces their ability to support or care for their children. This two-sided form pairs the applicant's health information release with a provider statement certifying the incapacity, its start and expected end, the diagnosis and its basis, and current and recommended treatment.
A currently licensed provider from the professions listed on the back completes and signs the provider side. The applicant completes the front, a release that can include specially protected mental health, substance use disorder and HIV information if initialed.
Download the current version from the source each time; forms change without notice.
Determination of Incapacity for FANF Financial Assistance
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Only the currently licensed providers listed on the form: physician, physician assistant, APRN, board-certified psychologist, clinical mental health counselor, pastoral psychotherapist, independent clinical social worker, alcohol and drug counselor (MLADC only) and marriage and family therapist. The provider checks their profession before completing the statements.
The form says the individual must be incapacitated so their ability to support or care for their children is substantially reduced, and either the incapacity is expected to last 30 continuous days from the FANF application date, or it lasted 30 continuous days in the 90 days before the application date.
The form states that payment of any separate charge for completing it is the patient's responsibility. DHHS does not list a fee or reimbursement for the provider on the form.