You may choose an Authorized Representative (AR) to help you apply for or get benefits.
Choosing: You must choose your own AR. Your AR must agree to help you.
Duties: check off the things that you want your AR to do for you, such as get, fill out, and sign applications, forms, and other DHHS paperwork.
Client signature: the client authorizes the AR to perform the duties checked on this form until the client or the AR tells DHHS of a change.
AR signature: the AR agrees to represent the client until the AR or the client tells DHHS of a change.
| Question | Answer |
|---|---|
| Form Name | BFA Form 778 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 9 min |
| Edition | Rev 09/23 |
| Issuing agency | NH Department of Health and Human Services (DHHS) |
| Where to send | Centralized Scanning Unit (CSU), P.O. Box 181, Concord, NH 03301 |
| Other names | 778, BFA 778, BFA Form 778, Form 778, Authorized Representative Declaration |
| Official source | BFA Form 778 (Rev 09/23), NH Department of Health and Human Services |
Dfa Form 778 isn’t the one you’re looking for?