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 1085, State of Texas Emergency Assistance Registry
Form 5875, HCS Waiver Program Self-Assessment Certification
Form 5920, TxHmL Waiver Program Self-Assessment Certification
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
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 3639, Prescribed Pediatric Extended Care Center Informal Dispute Resolution Request
Form 3648, DAHS Informal Dispute Resolution (IDR) Request