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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 1060, Health and Developmental Services (HDS) Promotion and Outreach Quarterly Report Promotion and Outreach Quarterly Report
Form 3202, Application to Operate or Close a Faith-Based Chemical Dependency Treatment
Form 3625, CLASS and CFC Documentation of Services Delivered ES
Form 3235, Licensed Chemical Dependency Counselor License Renewal Application
Form H1253, Verification of Health Insurance Policy
Form 3260, Licensed Chemical Dependency Counselor Intern Supervision Assessment
Form H1852, List of Resident Participants in the Supplemental Nutrition Assistance Program (SNAP) ES
Form 3203, Narcotic or Opioid Treatment Program Application
Form 3214, Chemical Dependency Treatment Facility Satellite Site Notification
Form 1092, Change of Ownership Transfer Affidavit
Form 3259, Chemical Dependency Treatment Facility Court Commitment or Emergency Detention Acceptance Application
Form H1988, Disaster Assistance Grants
Form 3646, Request for Formal Hearing
Form H1008-A, Warrant Inquiry and EBT Benefit Conversion and Affidavit for Non-receipt of Warrant
Form 6108, Chemical Dependency Treatment Facility and Narcotic Treatment Program Incident Report
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