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 8617, Individualized Skills and Socialization Enhanced Staffing Rate
Form 8616, In-Home Individualized Skills and Socialization Service Delivery Log
Form 1124, Facility Request
Form 3231, Crisis Stabilization Unit (CSU) License Renewal Application
Form 3649, Assisted Living Facility Background Disclosure Statement for Applicants for Employment
Form 3217, Psychiatric Hospital License Renewal Application
Form 3219, Multiple Location Psychiatric Hospital License Renewal Application
Form 3209, Chemical Dependency Treatment Facility Licensure Application Checklist for Change in Status Applicants
Form 3208, Chemical Dependency Treatment Facility Licensure Application Checklist for Initial Applicants
Form 1015, LMHA PASRR Specialized Services Discussion Checklist
Form 3650, Assisted Living Facility Memory Care Disclosure Statement
Form 3261, Licensed Chemical Dependency Counselor Intern Direct Observation Documentation
Form 3263, Crisis Stabilization Unit License Application
Form 1017, Burial or Cremation Assistance Registry Application
Form 1018, Burial or Cremation Assistance Registry Information Request