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 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
Form H1270, Data Integrity SAVERR Notification
Form 8401, Employment First Discovery Tool
Form 4807-D, Action Taken on Hearing Decision
Form 4800-DA, 4800-D Addendum