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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 4116-DME, ICF/IID Durable Medical Equipment Summary Sheet
Form 3159, Final Report of Expenditures
Form 3108, Dental Report
Form 1505, Request for Due-Process Hearing and/or Mediation ES
Form 3111, End-Stage Renal Disease Evaluation
Form 3709, Medicaid Bed Waiver Application for Nursing Facilities
Form 2038, Key Performance Measure Target Revision
Form 3156, Quarterly Program Income Report
Form 2900, Request to the Centralized Background Check Unit to Offer Due Process
Form 4205, Consent by Foster Parents or Medical Consenters for Health Passport ES
Form 4202, Contractor Notice of Appeal Rights (ECI)
Form H4870, Client Complaint of Discrimination ES
Form 8609, State Long-Term Care Ombudsman Program Complaint for Regulatory Services Investigation
Form 8620, Long-Term Care Ombudsman Activity Report
Form 8613, Office of the State Long-term Care Ombudsman Conflict of Interest Identification, Removal and Remedy
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