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 H0090-I, Notice of Admission, Departure, Readmission or Death of an Applicant/Recipient of Supplemental Security Income and/or Medical Assistance Only in a State Institution
Form H0065-MBIC, Hardship Form (Medicaid Buy-In for Children) ES
Form H0062-MBIC, Late Payment Notice ES
Form H0059, Notification of Annuity Remainder Beneficiary ES
Form H0057, Long-Term Care Partnership (LTCP) Resource Worksheet
Form H0056, Notice of Opportunity to Designate Countable Resources ES
Form H0055, Verification of Long-Term Care Insurance Policies
Form H0053, Medicaid Buy-In Potential Eligibility Notice ES
Form H0052, Medicaid Buy-In Refund Notice
Form H0051, Medicaid Buy-In Premium Payment Notice
Form H0004, Consent for a Person Sponsoring an Immigrant ES
Form H1163, TWC Employment Registration
Form H1146-M, Medicaid Report (Manual) ES
Form H1140, Verification of Benefits ES
Form H1139, Medical Expense Verification