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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 6500, DBMD and CFC Individual Plan of Care (IPC)
Form 4211, Early Childhood Intervention (ECI) Services - Respite Funding Agreement ES
Form 3216, Psychiatric Hospital License Application
Form 3210, Ambulatory Surgical Center License Application
Form 3218, Multiple Location Psychiatric Hospital License Application
Form 3204, End Stage Renal Disease Facility License Application
Form 3229, License Application to Operate a Multiple Location General or Special Hospital
Form 3246, Eligibility Determination Application for Early Termination of a Person’s Obligation to Register
Form 3225, Application for Certification – Supplement to CMS 116
Form 3227, Special Care Facility License Application
Form 3200, Abortion Facility License Application
Form 3015, Application for a Child Care Administrator License or a Child-Placing Agency Administrator License
Form 2260, LIDDA Permanency Planning Instrument (PPI) for Children Younger Than 22 Years, Family Directed Plan ES
Form 8578, Intellectual Disability or Related Conditions - ID/RC Assessment
Form 1051, Request for Determination of Intellectual Disability (DID)
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