Member Handbooks and Forms

• NH Medicaid Member Handbook - English: Effective January 1, 2023 (PDF)
• NH Medicaid Member Handbook - Spanish: Effective January 1, 2023 (PDF)
• Addendum to the Member Handbook for All Members - English: Effective July 17, 2022 (PDF)
• Addendum to the Member Handbook for All Members - Spanish: Effective July 17, 2022 (PDF)

Hard copies of the Member Handbook or other materials may be requested by calling Member Services.

• Welcome Kit Benefits Booklet - English (PDF)
• Welcome Kit Benefits Booklet - Spanish (PDF)
• Welcome Kit Forms Booklet - English (PDF) 
• Welcome Kit Forms Booklet - Spanish (PDF)
• Medicaid Member ID Card (PDF) 
• Granite Advantage Member ID Card (PDF)

NH Healthy Families Provider Directory (PDF)

*For a copy of the Provider Directory in another language, please contact our Member Services department at 1-866-769-3085

• Benefits and Services Overview Flyer - English (PDF) 
• Benefits and Services Overview Flyer - Spanish (PDF)
• Mental Health Champion Attestation Form (PDF)
• My Health Pays Flyer - English (PDF) 
• My Health Pays Flyer - Spanish (PDF)
• NH Healthy Families Mobile App Flyer (PDF)
• Ready for My Recovery Brochure - English (PDF)
• Ready for My Recovery Brochure - Spanish (PDF)
• Start Smart for Baby Flyer - English (PDF) 
• Start Smart for Baby Flyer - Spanish (PDF)
• Transportation Flyer - English (PDF) 
• Transportation Flyer - Spanish (PDF)
• Where to Go for Care Flyer (PDF)
• Where to Go for Care Flyer - Spanish (PDF)

Find a Provider Tool Guide (PDF)

• Authorized Representative Form – Grievances & Appeals (PDF)
• Authorization to Disclose Health Information Form (PDF)
• Authorization to Disclose Health Information Form - Spanish (PDF)
• Health Risk Assessment Form - English (PDF)
• Health Risk Assessment Form - Spanish (PDF)
• Healthy Kids Club Application (PDF)
• Member Appeal Request Form (PDF)
• Mobility Determination for Non-Emergency Medical Transportation Universal Form for All Medicaid Plans (PDF)
  In a collaborative effort among DHHS, AmeriHealth Caritas New Hampshire, BMC HealthNet Plan/Well Sense Health Plan and NH Healthy Families, the All MCO Workgroup has developed a new Mobility Form that will be used for all members. All of the respective NEMT Brokers will accept the same form going forward. This was done to enhance the current process and to ease the administrative responsibilities for our provider community. When a special NEMT accommodation is needed, this form will be sent to the provider’s office to be completed on behalf of their patient’s transportation needs starting in June 2021. The current forms that have already been completed for our members will continue to be in effect until they are phased out by the updated form.
• Notification of Pregnancy Form - English (PDF)
• Notification of Pregnancy Form - Spanish (PDF)
• Parental Consent Form - MTM (PDF)
• PCP Change Form - English (PDF)
• PCP Change Form - Spanish (PDF)
• Plan of Self Care Form - English (PDF)
• Plan of Self Care Form - Spanish (PDF)
• Prescription Claim Reimbursement Form (PDF)
• Ready for My Recovery Brochure (PDF)
• Ready for My Recovery Form - English (PDF)
  • NEW! Easy to use webform available here
• Ready for My Recovery Form - Spanish (PDF)
• Ready for My Recovery 1-Year Attestation Form - English (PDF)
  • NEW! Easy to use webform available here
• Ready for My Recovery 1-Year Attestation Form - Spanish (PDF)
• Revocation of Authorization to Disclose Health Information Form (PDF)
• Transportation Reimbursement Form - English (PDF)
• Transportation Reimbursement Form - Spanish (PDF)

• Helpful Links
• Kicks for Kids Well Child Visit Raflle Program (PDF)
• Photo and Testimonial Consent Form (PDF)