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 1590, Request for a Fair Hearing Exception
Form 1032, Residential Care Copayment Worksheet
Form 5156, Referral Checklist
Form 5014, Report of Death or Service Termination
Form 5013, Contractor Referral
Form 5011, Statement of Deficiencies and Plan of Corrections
Form H4100, Money Receipt ES
Form H1177, Transmittal and Receipt for Controlled EBT Documents
Form H1175, EBT Change Request
Form H1174, Inventory of EBT Cards
Form H1172, EBT Card, PIN and Data Entry Request ES
Form H1111, Card Order Discrepancy Verification
Form H4861, Receipt of Notice ES
Form H4857, Notice of Decision, Administrative Disqualification Hearing
Form H4856, Request for Another Appointment for Administrative Disqualification Hearing