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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 3681-C, Community Services Contract Application Addendum C - Emergency Response Services
Form 3224, Freestanding Emergency Medical Care Facility License Renewal Application
Form 8619, State Long-Term Care Ombudsman Program Case Record
Form 5507-NAR, Request for Waiver of Nurse Aide Training and Competency Evaluation
Form 2806, Authorization of Youth Empowerment Services (YES) Waiver Services ES
Form 1085, State of Texas Emergency Assistance Registry
Form 5875, HCS Waiver Program Self-Assessment Certification
Form 5920, TxHmL Waiver Program Self-Assessment Certification
Form 2020, Notification of Readiness for Initial Survey
Form 3109, Provider Information Change
Form 8610, State Long-term Care Ombudsman Program Certified Ombudsman II Recommendation and Approval
Form 8622, Consent for Criminal History Check
Form 3301, Residential Treatment Center Project Family Agreement
Form 3613, Provider Investigation Report with Fax Cover Sheet (Home Health, Hospice and Personal Assistance Services Provider Use Only)
Form 3028, Hemophilia Assistance Program (HAP) Provider Enrollment
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