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 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
Form 3261, Licensed Chemical Dependency Counselor Intern Direct Observation Documentation December 12, 2022
Form 5528-NAR, Request to Retest for Nurse Aides in Expired Status December 9, 2022
Form 5507-NAR, Request for Waiver of Nurse Aide Training and Competency Evaluation December 9, 2022
Form 5514-NATCEP, Application for Nurse Aide Training and Competency Evaluation Program (NATCEP) December 9, 2022
Form 5505-NAR, Request for Entry on the Texas Nurse Aide Registry Through Reciprocity December 9, 2022
Form 8571, Request to Change Interest List Information for Home 
and Community-based Services (HCS) or Texas Home Living (TxHmL) December 8, 2022
Form 3264, General and Special Hospital Multiple Location License Renewal Application December 1, 2022
Form 3263, Crisis Stabilization Unit License Application November 30, 2022
Form 3203, Narcotic/Opioid Treatment Program Application November 30, 2022