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 3651, Memory Care Disclosure Statement for Nursing Facilities
Form 3258, Licensed Chemical Dependency Counselor Program Peer Assistance Program Access Attestation
Form 3257, Licensed Chemical Dependency Counselor Peer Assistance Program Application
Form 3647, Assisted Living Disclosure Statement
Form 3641-A, Alzheimer's Disclosure Statement for Nursing Facilities
Form 3641, Alzheimer's Assisted Living Disclosure Statement
Form 3947, Specialized Telecommunications Assistance Program (STAP) Request for New Authorized Equipment
Form 8203, Subcontractor Attestation Form
Form 8204, Subcontractor Credentialing Attestation Form
Form 2407, Informal Dispute Resolution (IDR) Request
Form H1958-A, Other Needs Assistance Program Stuffer
Form 3708-A, HCS/TxHmL Amelioration Request
Form 3708, Regulatory Services NF, ALF and ICF/IID Amelioration Request
Form 2869, Permission to Collect Protected Health, Confidential and Nonconfidential Information
Form 3255, Fire Safety Survey Report for Hospitals and Crisis Stabilization Units