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 2360, Negative PASRR Evaluation Letter ES
Form 2805, Youth Empowerment Services (YES) Waiver Comprehensive Waiver Provider (CWP) Selection ES
Form 2809, Youth Empowerment Services (YES) Waiver Verification of Freedom of Choice ES
Form 2811, Youth Empowerment Services (YES) Waiver Letter of Withdrawal ES
Form 1337, CHIP Drug Rebate Agreement
Form 2828, Youth Empowerment Services (YES) Waiver Inquiry List Attestation Inquiry List Attestation
Form 2821, Youth Empowerment Services (YES) Waiver Electronic Visit Verification (EVV) Responsibilities and Additional Information ES
Form 8604, Transition Assistance Services (TAS) Assessment and Authorization
Form 2803, Youth Empowerment Services (YES) Waiver Critical Incident Report (CIR)
Form 2801, Youth Empowerment Services (YES) Waiver Fair Hearing Request ES
Form H1073, Personal Responsibility Agreement ES
Form 1349, Drug Utilization Review Board Annual Disclosure
Form 3264, General and Special Hospital Multiple Location License Renewal Application
Form 1315, Drug Shortage Notification and Expedited Formulary or Preferred Drug List Request
Form 3232, General or Special Hospital License Renewal Application