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 1740, Service Backup Plan ES
Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option ES
Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services ES
Form 1582, Consumer Directed Services Responsibilities ES
Form 1579, Referral for Relocation Services ES
Form 0003, Authorization to Furnish Information
Form H1746-B, Batch Cover Sheet
Form 4801, State Fair Hearing Evidence Packet Cover Page ES
Form 2606, Managed Care Enrollment Processing Delay ES
Form H2118, STAR+PLUS HCBS Program Interest List – Confirmation of Continued Interest ES
Form H2064, Gap in Enrollment for Medicaid Managed Care Members
Form H2062, STAR+PLUS Waiver Activity Record
Form H2060-A, Addendum to Form H2060 ES
Form H2060, Needs Assessment Questionnaire and Task/Hour Guide ES
Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services ES