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 1487, Designation of Representative ES
Form H1131, Individually Identifiable Health Information Fax Transmittal
Form H1200-MBIC, Application for Benefits – Medicaid Buy-In for Children ES
Form H1200-MSP-C, Medicare Savings Program Notice ES
Form H1200-MSP-D, Medicare Savings Program Denial Notice ES
Form H1200-PFS, Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement
Form H1201, MAO Worksheet
Form H1201-A, Client Declaration or Streamline Review Worksheet
Form H1201-EZ, Medicaid Eligibility Client Declaration Worksheet
Form H1202-A, MAO Worksheet-Income Changes
Form H1202-B, MAO Worksheet-Other Changes
Form H1204, Long Term Care Options
Form H1207, Notification of Eligibility - Special Medicaid Programs
Form H1207-A, Notification of Eligibility Special Medicaid Program (State Facilities)
Form H1214, Request for Pension Information