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 3038, Children’s Autism Program Family Cost Share Attestation Worksheet November 29, 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 1342, Antiviral Agents for Hepatitis C Virus Initial Request – Standard PA Addendum (Medicaid) November 28, 2022
Form 2870, Permission to Disclose Protected Health and Other Confidential Information November 28, 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
Forms 3207, Chemical Dependency Treatment Facility Licensure Application November 16, 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 2806, Authorization of Youth Empowerment Services (YES) Waiver Services ES November 14, 2022
Form 3906, Application for Specialized Telecommunications Assistance Program (STAP) ES November 14, 2022
Form 3651, Memory Care Disclosure Statement for Nursing Facilities November 10, 2022
Form 3258, Licensed Chemical Dependency Counselor Program Peer Assistance Program Access Attestation November 10, 2022
Form 3257, Licensed Chemical Dependency Counselor Peer Assistance Program Application November 10, 2022