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 4121, Home and Community-based Services/Texas Home Living Community First Choice Personal Assistance Services/Habilitation ES
Form 3651, Memory Care Disclosure Statement for Nursing Facilities
Form 3258, Licensed Chemical Dependency Counselor Program Peer Assistance Program Access Attestation
Form 3257, Licensed Chemical Dependency Counselor Peer Assistance Program Application
Form 3259, Chemical Dependency Treatment Facility Court Commitment or Emergency Detention Acceptance Application
Form 3647, Assisted Living Disclosure Statement
Form 3256, Chemical Dependency Treatment Facility Variance Request Application
Form 4214, Request for Non-Emergency Medical Transportation (NEMT) Services
Form 3641-A, Alzheimer's Disclosure Statement for Nursing Facilities
Form 3641, Alzheimer's Assisted Living Disclosure Statement
Form 3955, Application for Driver Identification Visor Card
Form 3947, Specialized Telecommunications Assistance Program (STAP) Request for New Authorized Equipment
Form 3234, Council for Sex Offender Treatment (CSOT) Request for Criminal History Evaluation
Form 3239, Initial Licensed Sex Offender Treatment Provider or Affiliate Sex Offender Treatment Provider Licensure Application
Form 3018, Administrator Licensing – Change in Contact Information