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 1063, Individual Profile – Nursing Facility
Form 1064, Habilitative Assessment
Form 2358, Habilitation Coordination Authorization Request
Form 3691, Service Area Designation
Form 3053, Notification of Rights and Responsibilities, Complaint Procedures, and Allegations of Abuse, Neglect or Exploitation ES
Form 2071, Monthly Report of Nutrition Services Incentive Program (NSIP) Eligible Meals and Title XX Meals
Form 2031-G, Designation of Authorized Individual(s) – Governmental Entity
Form 1722, Employer's Selection for Electronic Visit Verification Responsibilities ES
Form 3854, Contract or Program Compliance — Individual Record Evaluation (Emergency Response Services)
Form 3061, Emergency Response Services Financial Errors Standard
Form 4719, Fire Drill Report
Form 3683, Day Activity and Health Services Daily Attendance Record
Form 3682, Day Activity and Health Services Daily Transportation Record
Form 3681-B, Community Services Contract Application Addendum B - Adult Foster Care Provider Questionnaire
Form 3681-A, Community Services Contract Application - Addendum A