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 H1713, Acknowledgement of Family Violence Good Cause Option and Contact Resources ES
Form 2186, Home and Community-based Service (HCS) and Texas Home Living (TxHmL) Implementation Plan for Individualized Skills and Socialization
Form 2432, CLASS and DBMD Program Vehicle Evaluation
Form 3225, Application for Certification – Supplement to CMS 116
Form 2128, 120 Day Notice ES
Form 3274, Application to Add a Mobile Stroke Unit to a Hospital License
Form 3230, Application for HHSC Approval to Operate a Hospital at Home Program
Form 2825, Youth Empowerment Services (YES) Waiver - Death Review
Form 1074, Transition Support Teams (TST) - Case Review Request
Form H1200-MBI, Application for Benefits – Medicaid Buy-In ES
Form 2962, Verification of Liability Insurance
Form 1055, LIDDA State Supported Living Center (SSLC) Transition Reporting ES
Form 3161, Consumer Demographic Information
Form 2027, Home-Delivered Meals Waiver Request
Form 5506-NAR, Texas Nurse Aide Registry Employment Verification