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 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
Form H1214-FTI, Request for Pension Information - FTI
Form H1215, Report of Delay in Certification
Form H1217, Quality Assurance Monitoring System
Form H1222, Private Health Insurance Information
Form H1233, SMIB Memorandum
Form H1224, SSI Monitoring Letter
Form H1225, Restitution ES
Form H1226, Transfer of Assets/Undue Hardship Notification ES
Form H1228, Application Letter ES
Form H1228-A, Medicaid for the Elderly and People with Disabilities -- Application Information ES
Form H1230, Notification of Eligibility - Regular Medicaid Benefits ES