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 H3675, Application Acknowledgement ES
Form 8510, HCS/TxHmL CFC PAS/HAB Assessment
Form H0054, Medicaid Buy-In Eligibility Notice ES
Form 5205, Breast and Cervical Diagnostic Procedure Complication Reimbursement Request
Form 5204, Office-based Procedures Performed in an Ambulatory Surgical Center Pre-Authorization Request
Form 5203, Breast MRI Pre-Authorization Request
Form 2279, Request for Service Waiver
Form 2278, Determination of Type of Meal
Form 2277, Client Information Release ES
Form 2275, Client Rights and Responsibilities ES
Form 8627, Request for Review of Individual Plan of Care (IPC) Cost Over Maximum Cost Ceiling Cover Sheet
Form 8608, Sample Appeal Letter
Form 8601, Verification of Freedom of Choice
Form 8599, Individual Plan of Care (IPC) Cover Sheet
Form 8586, TxHmL Service Coordination Notification