Forms

HHS forms are used every day to perform tasks such as applying for benefits, contracting to provide goods or services, reporting incidents, declaring end of life wishes, and conducting other business.

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ES = Spanish version available.

Title	Last updated
Form 1722, Employer's Selection for Electronic Visit Verification Responsibilities ES	June 1, 2023
Form 1720, Appointment of a Designated Representative ES	June 1, 2023
Form 3639, Prescribed Pediatric Extended Care Center Informal Dispute Resolution Request	June 1, 2023
Form H1710, Payment Identification ES	May 31, 2023
Form 8401, Employment First Uniform Assessment	May 26, 2023
Form 3648, DAHS Informal Dispute Resolution (IDR) Request	May 25, 2023
Form 3698, Resident Fund Surety Bond	May 25, 2023
Form 3687, Provider Agency Findings of Fiscal Monitoring Review	May 25, 2023
Form 1718, Electronic Visit Verification (EVV) Responsibilities and Additional Information (Managed Care Organization) ES	May 25, 2023
Form 3046, Statement of Applicant's Rights and Responsibilities ES	May 24, 2023
Form 3246, Eligibility Determination Application for Early Termination of a Person’s Obligation to Register	May 22, 2023
Form 8763, Informed Consent or Authorization for Administration of Psychotropic Medication	May 22, 2023
Form 2128, 120 Day Notice ES	May 22, 2023
Form 3031, Children with Special Health Care Needs (CSHCN) Program Application ES	May 19, 2023
Form H1899, Unauthorized Use Replacement Benefit Eligibility Notice	May 18, 2023