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 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
Form 3595, IPP Service Review
Form 3591, CLASS IPC/IDRC Cover Sheet
Form 2076, Authorization to Release Medical Information ES
Form 1739, Service Provider Agreement ES
Form 1351, Request to Withdraw from the CLASS Application Process ES
Form 1041, Refusal of PASRR Mental Illness Specialized Services ES
Form H4808, Notice of Change in Applied Income/Notice of Denial of Medical Assistance
Form 3074, Physician Certification of Terminal Illness ES