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.

Title
Form SS-5, Application for a Social Security Number Card (Original, Replacement, or Correction)
Form H1054-IME, Receipt of Dental Service ES
Form H1052-IME, Notice of Delay in Decision for Incurred Medical Expense – Action Needed ES
Form H1051-IME, Receipt of Durable Medical Equipment ES
Form H1049, Client's Statement of Self-Employment Income ES
Form H1039, Medical Insurance Input
Form H1038, Medical Facility Referral
Form H1035, Pre-Screening Result for Medicaid
Form H1028-MBIC, Employment Verification (Medicaid Buy-In for Children)
Form H1028-A, Employment Verification (Aged and Disabled Programs)
Form H1027-C, Medicaid Eligibility Verification - QMB
Form H1027-B, Medicaid Eligibility Verification - MQMB
Form H1020-A, Sources of Proof ES
Form H1020, Request for Information or Action ES
Form H1016, Supplemental Security Income Referral