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 H1866, Federal Tax Information Visitor Access Log ES
Form H2076, Authorization to Release Medical Information
Form H3033, Report of Physical or Mental Examination
Form H3080, Notification of Eligibility - Qualifying Individuals Program
Form H3081, QI Transaction Report
Form H3618-A, Resident Transaction Notice for Designated Vendor Numbers
Form H4831, Fraud Referral Log
Form H5017-MBIC, Items We Need from You ES
Form H5017-MEPD, Items We Need from You ES
Form H5018-MBIC, Denial Notice (Medicaid Buy-In for Children) ES
Form H5020-MBIC, Hardship Waiver Denied (Medicaid Buy-In for Children) ES
Form H5021-MBIC, Initial Certification (Medicaid Buy-In for Children) ES
Form H5022-MBIC, Notice of Change in Monthly Payment or Cost Share Limit (Medicaid Buy-In for Children) ES
Form H5023-MBIC, Prior Months Eligibility (Medicaid Buy-In for Children) ES
Form H5024-MBIC, Termination Notice (Medicaid Buy-In for Children) ES