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.

ES = Spanish version available.

Title
Form H1019, Report of Change ES
Form H1713, Acknowledgement of Family Violence Good Cause Option and Contact Resources ES
Form 4116, Authorization for Expenditures
Form H1200-EZ, Application for Assistance - Aged and Disabled ES
Form H1200-PFS, Medicaid Application for Assistance for Residents of State Facilities Property and Financial Statement ES
Form 8647, Service Coordination Assessment – Intellectual Disability Services ES
Form H2065-D, Notification of Managed Care Program Services ES
Form H1200-A, Medical Assistance Only (MAO) Recertification ES
Declaration for Mental Health Treatment (DMHT) ES
Form 1018, Burial or Cremation Assistance Registry Information Request
Form 1017, Burial or Cremation Assistance Registry Application
Form 7243, Emergency Phone Numbers
Form 7270, Children's Records Evaluation of a Licensed Child Care Home or Registered Child Care Home
Form 7261, Center Records Evaluation
Form 2982, Personal History Statement