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 6700, Use and Release of Health Information Authorization ES
Form 1090, Oral Evaluation and Fluoride Varnish Certification Application
Form 4103, Vendor Invoice Summary
Form 5538-MA, Understanding of Required Criminal Background Check
Form 5534, Medication Aide General Statement Enrollment
Form 1024, Individual Status Summary
Form H1014-A, Children's Health Care Benefits - Final Reminder ES
Form H1700-3, Individual Service Plan – Signature Page ES
Form 5842, TxHmL Financial Eligibility Information
Form 1354, PCSK9 Inhibitors Authorization Request (Medicaid Fee-for-Service)
Form 1322, Texas Medicaid Prior Authorization Reconsideration Request
Form 2247, Interest List Contact Notification ES
Form 2097, Provider Contract Assignment Notification ES
Form 2362, Receipt Certification by a Qualified Rehabilitation Professional
Form 2065-C, Notification of Ineligibility or Suspension of Waiver Services