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 1347, Emflaza Standard Prior Authorization Addendum (Medicaid) January 11, 2023
Form 6325, Home and Community Support Services Agency Medicare Certified Agency Relocation Questionnaire January 10, 2023
Form 3219, Multiple Location Psychiatric Hospital License Renewal Application January 5, 2023
Form 3224, Freestanding Emergency Medical Care Facility License Renewal Application January 4, 2023
Form 3202, Faith-Based Chemical Dependency Treatment Program Application for Exemption Registration January 2, 2023
Form 8576, Individual Profile Information January 2, 2023
Form 3209, Chemical Dependency Treatment Facility Licensure Application Checklist for Change in Status Applicants December 30, 2022
Form 3208, Chemical Dependency Treatment Facility Licensure Application Checklist for Initial Applicants December 30, 2022
Form 3906, Application for Specialized Telecommunications Assistance Program (STAP) ES December 21, 2022
Form H1017-P, Notice of Benefit Denial/Personal Responsibility Agreement (PRA) Reasons ES December 20, 2022
Form 1015, LMHA PASRR Specialized Services Discussion Checklist December 20, 2022
Form 3650, Assisted Living Facility Memory Care Disclosure Statement December 15, 2022
Form 3907, Application for Specialized Telecommunications Assistance Program (STAP) Speech Generating Devices ES December 15, 2022
Form 3262, Licensed Chemical Dependency Counselor Intern Supervised Work Experience Documentation December 12, 2022
Form 3260, Licensed Chemical Dependency Counselor Intern Supervision Assessment December 12, 2022