Member Handbooks and Forms

• NH Medicaid Member Handbook - English: Effective January 1, 2025 (PDF)
• NH Medicaid Member Handbook - Spanish: Effective January 1, 2025 (PDF)
• Addendum to the Member Handbook for All Members - English: Effective January 1, 2025 (PDF)
• Addendum to the Member Handbook for All Members - Spanish: Effective January 1, 2025 (PDF)

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

Other available language Member Handbooks (please note the year associated with each, updated versions are coming soon):

• NH Medicaid Member Handbook - Arabic: Effective January 1, 2025 (PDF)
• NH Medicaid Member Handbook - Nepali: Effective January 1, 2025 (PDF)
• NH Medicaid Member Handbook 2024 – Kinyarwanda (PDF)
• NH Medicaid Member Handbook 2021 - Arabic (PDF)
• NH Medicaid Member Handbook 2021 – Dari (PDF)
• NH Medicaid Member Handbook 2021 – Nepali (PDF)

• Welcome Kit Primary Care and Prevention Focused Care Model (PCPFCM) Booklet - English (PDF)
• Welcome Kit Primary Care and Prevention Focused Care Model (PCPFCM) 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

NH Healthy Families Provider Directory Machine-Readable File (CSV)

In accordance with the CMS Transparency in Coverage Final Rule (84 FR 65524), NH Healthy Families has made public the Provider Directory in a machine-readable file format (MRF).

• NH Healthy Families Provider Directory (CSV)

• Behavioral Health for the Whole Familiy (PDF)
• Benefits and Services Overview Flyer - English (PDF) 
• Benefits and Services Overview Flyer - Spanish (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) Coming Soon
• Start Smart for Baby Flyer - English (PDF) 
• Start Smart for Baby Flyer - Spanish (PDF)
• Transportation Flyer - English (PDF)
  Remember: Use Family and Friends first! It's easy to schedule your trips by calling MTM at 1-888-597-1192, go online at mtm.mtmlink.net or use the MTM Link Member app before your appointment and schedule your reimbursement trip.

• Transportation Flyer - Spanish (PDF)
• Transportation: MTM Link Brochure (PDF)
• Urgent Care VS Emergency Room Flyer - English (PDF)
• Urgent Care VS Emergency Room Flyer - Spanish (PDF)
• Where to Go for Care Flyer (PDF)
• Where to Go for Care Flyer - Spanish (PDF)
• Youth Programs - English (PDF)
• Youth Programs - Spanish (PDF)

Find a Provider Tool Guide (PDF)
Medicaid Coverage Out of Area Information for Youth Away at School (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. 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.
• Member Notification of Pregnancy Form - English (PDF)
• Member 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)
  • Easy to use webform available here
• Ready for My Recovery Form - Spanish (PDF)
• Ready for My Recovery 1-Year Attestation Form - English (PDF)
  • 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)

• Kicks for Kids Lead Screening Program (PDF)
• Disenrollment Rights (PDF)
• Helpful Links
• Photo and Testimonial Consent Form (PDF)