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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Title Last updated
Form 3217, Psychiatric Hospital License Renewal Application January 12, 2023
Form 3218, Multiple Location Psychiatric Hospital License Application January 12, 2023
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 3232, General or Special Hospital License Renewal Application January 4, 2023
Form 3224, Freestanding Emergency Medical Care Facility License Renewal Application January 4, 2023
Form 3228, Application for a License to Operate a General or Special Hospital January 4, 2023
Form 3216, Psychiatric Hospital License Application January 4, 2023
Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order January 3, 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