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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 H4870, Client Complaint of Discrimination ES
Form 8609, State Long-Term Care Ombudsman Program Complaint for Regulatory Services Investigation
Form 8613, Office of the State Long-term Care Ombudsman Conflict of Interest Identification, Removal and Remedy
Form 8728, ICF/IID Augmentative Communication Device (ACD) System Authorization
Form 8729, ICF/IID ACD Delivery and Completion of Purchase Confirmation
Form 3243, Affiliate Sex Offender Treatment Provider or Licensed Sex Offender Treatment Provider Name Change or Duplicate License Application
Form 3245, Initial Licensed Sex Offender Treatment Provider Supervisor Application
Form 3736, Application for State License to Operate a Type C Assisted Living Facility
Form 1091, First Dental Home Certification Application
Form 1141, PACE/SASO Registration Disenrollment
Form H2581, Choices Noncooperation Report
Form 0006, Service Provider Printed Forms Order
Form 1903, Child Support Certification
Form 5498-NATCEP, Nurse Aide Daily Sign-in Sheet
Form 3925, Special Needs Funds Request for Communication Access
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