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 1124, Facility Request February 1, 2023
Form H1173, EBT Card Issuance Log January 31, 2023
Form 1046, Request for HCS Adult NF Transition Slot January 25, 2023
Form 1047, Request for HCS Targeted NF Diversion Slot January 25, 2023
Form 1058, Request for Home and Community-based Services Crisis Diversion Slot January 25, 2023
Form 1347, Emflaza Standard Prior Authorization Addendum (Medicaid) January 11, 2023
Form H1017-P, Notice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons ES December 20, 2022
Form 1015, LMHA PASRR Specialized Services Discussion Checklist December 20, 2022
Form 1338, Cystic Fibrosis Agents (Kalydeco/Orkambi/Symdeko) – Medicaid Standard PA Addendum November 29, 2022
Form 1321, Synagis Standard Prior Authorization Addendum (Medicaid) November 29, 2022
Form H1855, Affidavit for Nonreceipt or Destroyed Supplemental Nutrition Assistance Program (SNAP) Benefits ES November 18, 2022
Form H1185, Important Information About Your Lone Star Card November 18, 2022
Form 1017, Burial or Cremation Assistance Registry Application November 16, 2022
Form 1018, Burial or Cremation Assistance Registry Information Request November 16, 2022
Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services ES November 8, 2022