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 3090, Nursing Health Screening Within 72 Hours of Community Placement
Form 3223, Licensed Chemical Dependency Counselor, Counselor Intern and Council on Sex Offender Treatment Complaint
Form 7266, Notification of Abuse, Neglect or Exploitation Deficiency
Form 2818, Critical Incident Report
Form 2817, Local Mental Health Authority (LMHA) or Local Behavioral Health Authority (LBHA) Monthly Report
Form 2816, Residential Treatment Center Project Referral Checklist
Form 3222, Confidentiality of Patient Records
Form 3221, Health Care Facility Certification Under Executive Order GA-15
Form 2842, Temporary Emergency Child Care Operation – Plan of Operation
Form 7265, Attestation of Child Day Care for Essential Workers - Child Care Regulation ES
Form 7264, Attestation of Child Day Care for Protective Day Care - Child Care Regulation ES
Form 3220, COVID-19 Response Off-Site Facility Application
Form 5004, Optional COVID-19 CHIP Provider Co-payment Attestation
Form 3834, Written Acknowledgement of Completion of Cybersecurity Training Program
Form 3089, HCBS-AMH Complaint