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 5402, Office of Communications – Media Release ES
Form 3217, Psychiatric Hospital License Renewal Application
Form 3218, Multiple Location Psychiatric Hospital License Application
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 5528-NAR, Request to Retest for Nurse Aides in Expired Status
Form 5514-NATCEP, Application for Nurse Aide Training and Competency Evaluation Program (NATCEP)