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 3266, Licensed Chemical Dependency Counselor (LCDC) License Application
Form 3248, Chemical Dependency Counselor Intern Registration Application
Form 3106, Comprehensive Rehabilitation Services Referral ES
Form 1290, Long Term Care Claim
Form 3681, Community Services Contract Application
Form 2962, Verification of Liability Insurance
Form 3207, Chemical Dependency Treatment Facility License Application
Form 3621, CLASS or CFC Individual Plan of Care
Form 3239, Initial Licensed Sex Offender Treatment Provider or Affiliate Sex Offender Treatment Provider Licensure Application
Form 3233, Licensed Chemical Dependency Counselor Program Request for Criminal History Evaluation
Form 3249, Hospital Waiver Request
Form 4210, Early Childhood Intervention (ECI) Services - Active-Duty Military Service Member, Military Veteran, Or Spouse Application for the Early Intervention Specialist Credential
Form 3955, Application for Driver Identification Visor Card
Form 2833, Single Skill Program Request for Exemption from Child Care Regulation
Form 8666, Volunteer Orientation Agreement