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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 6501, Individual Program Plan
Form 3628, Provider Agency Model Service Backup Plan
Form 3627, Specialized Nursing Certification
Form 3596, PAS/Habilitation Plan – CLASS/DBMD/CFC
Form 3594, Individual Plan of Care (IPC) Cover Sheet
Form 8606-A, Therapy Justifications – Attachment to IPP
Form 8606, Individual Program Plan (IPP)
Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications
Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation
Form 3657, Pre-Enrollment Assessment
Form 1053, Local Intellectual and Developmental Disabilities Authorities (LIDDA) Transition Plan
Form 3629, Individual Program Plan Addendum
Form 3624, Termination, Reduction or Denial of CLASS ES
Form 3623, Approval of Application for CLASS
Form 3622, Denial of Application for CLASS ES
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