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 1131, Individually Identifiable Health Information Fax Transmittal
Form 1025, Request for Information Medicare Advantage Coordination
Form 1023, Request for Services Funded by General Revenue
Form 8207, Telehealth Services Attestation
Form 3034, Provider Assessment Form
Form 1038, Consent for the Use of Audio-Only or Audio-Visual Communication ES
Form 1035, PASRR Consent for Use of Audio-Only and Audio-Visual Communication ES
Form H2065-A, Notification of Community Care Services ES
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 2279, Request for Service Waiver
Form 2278, Determination of Type of Meal