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 H2065-D, Notification of Managed Care Program Services ES
Form H1200-A, Medical Assistance Only (MAO) Recertification ES
Declaration for Mental Health Treatment (DMHT) ES
Form 1018, Burial or Cremation Assistance Registry Information Request
Form 1017, Burial or Cremation Assistance Registry Application
Form 7243, Emergency Phone Numbers
Form 7270, Children's Records Evaluation of a Licensed Child Care Home or Registered Child Care Home
Form 7261, Center Records Evaluation
Form 2982, Personal History Statement
Form 3071, Individual Election, Cancellation or Update ES
Form 2919, Request for a Registration Permit ES
Form 3212, Birthing Center License Application
Form 3706, Nursing Facility Customized Power Wheelchair (CPWC) Authorization
Form 1726, Relationship Definitions in Consumer Directed Services Employer's Acknowledgement and Certification ES
Form 1024, Individual Status Summary