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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 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
Form 1123, Review of Assisted Living Facility Type C
Form 2463, Emergency Dental Services
Form 2333, Nursing Facility Risk Criteria Scoring Form
Form 5605, Life Safety Code Overview Worksheet
Form 3619, Medicare/Skilled Nursing Facility Patient Transaction Notice
Form 1332, Pharmacy Ownership Transfer Affidavit
Form 8202, HCBS-AMH Program and YES Waiver Program Request for Technology Funding
Form 8201, HCBS-AMH Recovery Manager Settings Check
Form 3063, CSHCN Statement of Self-Employment Income ES
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