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 H1049-3, Self-Employment Income Worksheet
Form H1822, ABAWD Employment and Training Work Requirement Verification
Form H1017-P, Notice of Benefit Denial and Personal Responsibility Agreement (PRA) Reasons ES
Form H1017-B, Transitional Medicaid ES
Form H1013, Electronic Correspondence Confirmation Letter ES
Form H0064, State Kids Insurance Program (SKIP) Referral
Form 6502, Denial of Application for DB-MD
Form 6003, Autism Program and or Request for Advance Payment
Form 4208, ECI Services - TKIDS, TRAD, EIS Registry, Extranet and Data Upload Security Agreement ES
Form 3632, Withdrawal Confirmation
Form 3605, HCS Parent or Legally Authorized Representative (LAR) Contact Information for Individuals Under 22 Years of Age
Form 3042, MH Child and Adolescent Needs and Strengths (CANS) Ages 3 through 5 ES
Form 2897, OM Referral
Form 8600, Plan of Removal Provider Template
Form 2894, Consumer Services Report – OM Assessment