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
Form 3219, Multiple Location Psychiatric Hospital License Renewal Application
Form 3202, Faith-Based Chemical Dependency Treatment Program Application for Exemption Registration
Form 3209, Chemical Dependency Treatment Facility Licensure Application Checklist for Change in Status Applicants
Form 3208, Chemical Dependency Treatment Facility Licensure Application Checklist for Initial Applicants
Form 3906, Application for Specialized Telecommunications Assistance Program (STAP) ES
Form 3650, Assisted Living Facility Memory Care Disclosure Statement
Form 3907, Application for Specialized Telecommunications Assistance Program (STAP) Speech Generating Devices ES
Form 3262, Licensed Chemical Dependency Counselor Intern Supervised Work Experience Documentation
Form 3260, Licensed Chemical Dependency Counselor Intern Supervision Assessment
Form 3261, Licensed Chemical Dependency Counselor Intern Direct Observation Documentation
Form 3264, General and Special Hospital Multiple Location License Renewal Application
Form 3263, Crisis Stabilization Unit License Application
Form 3203, Narcotic/Opioid Treatment Program Application
Form 3207, Chemical Dependency Treatment Facility License Application
Form 3038, Children’s Autism Program Family Cost Share Attestation Worksheet