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
TF0610, Notice of Excessive Card Replacements
Form H0005, Policy Clarification Request (PCR)
Form 3032, Hemophilia Assistance Program (HAP) Physical Assessment
Form 4210, Early Childhood Intervention (ECI) Services - Active-Duty Military Service Member, Military Veteran, Or Spouse Application for the Early Intervention Specialist Credential
Form 3233, Licensed Chemical Dependency Counselor Program Request for Criminal History Evaluation
Form 3248, Chemical Dependency Counselor Intern Registration Application
Form 0013, Topic Nomination for Medical and Dental Benefits Consideration
Form 3029, Application for Program Benefits ES
Form 1902, Provider Application
Form 1321, Texas Medicaid Palivizumab (Synagis) Standard Prior Authorization Request
Form H1155, Request for Domicile Verification ES
Form 1057, Habilitation Service Plan HSP
Form 1012, Mental Illness and Dementia Resident Review
Form 2009, Preadmission Screening and Resident Review PASRR Report of Specialized Services Non-Compliance to Consumer Rights and Services CRS
Form 1014, Pre-Admission Screening and Resident Review PASRR Evaluation Summary Report ES