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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 2437, Notification of Nursing Facility Admission of Individual Under Age 22
Form 6700, Use and Release of Health Information Authorization ES
Form 1090, Oral Evaluation and Fluoride Varnish Certification Application
Form 3726, Notification of Adverse Change in Financial Condition
Form 3706, Nursing Facility Customized Power Wheelchair (CPWC) Authorization
Form 3639, Prescribed Pediatric Extended Care Center Informal Dispute Resolution Request
Form 3648, DAHS Informal Dispute Resolution (IDR) Request
Form 8623, State Long-Term Care Ombudsman Program Certified Ombudsman Application
Form 8206, Service Area Change Request
Form 4207, Individualized Family Service Plan (IFSP) Services ES
Form 2992, Supervisory Visit
Form 2991, General Residential Operation (GRO) Serious Incident Report (SIR)
Form 2990, Child Placing Agency (CPA) Serious Incident Report (SIR)
Form 2994, Child Placing Agency (CPA) Medication Log
Form 2993, General Residential Operations Medication Log
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