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 3257, Licensed Chemical Dependency Counselor Peer Assistance Program Application November 10, 2022
Form 3259, Chemical Dependency Treatment Facility Court Commitment or Emergency Detention Acceptance Application November 9, 2022
Form 3647, Assisted Living Disclosure Statement November 9, 2022
Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services ES November 8, 2022
Form 3256, Chemical Dependency Treatment Facility Variance Request Application November 8, 2022
Form 4214, Request for Non-Emergency Medical Transportation (NEMT) Services November 8, 2022
Form 3641-A, Alzheimer's Disclosure Statement for Nursing Facilities November 7, 2022
Form 3641, Alzheimer's Assisted Living Disclosure Statement November 7, 2022
Form 3955, Application for Driver Identification Visor Card November 7, 2022
Form 3947, Specialized Telecommunications Assistance Program (STAP) Request for New Authorized Equipment November 7, 2022
Form H1071, Family Violence Exemption for Medicaid and CHIP ES October 27, 2022
Form 8203, Subcontractor Attestation Form October 26, 2022
Form 8204, Subcontractor Credentialing Attestation Form October 26, 2022
Form 1051, Request for Determination of Intellectual Disability (DID) October 25, 2022
Form 1316, Pharmacy Electronic Remittance Advice Agreement October 21, 2022