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 5010, Enrollment Systems Attestation
Form 3060, CSHCN Eligibility Exemption Request ES
Form 3058, CSHCN Regional Verification Worksheet ES
Form 3211, Ambulatory Surgical Center License Renewal Addendum
Form 3725, Licensure Change of Ownership Affidavit
Form 1208, Memorandum of Understanding Between Texas Health and Human Services Commission (HHSC) and Certified Community Behavioral Health Clinic (CCBHC)
Form 1402, Value-Based Agreement Concept
Form 3201, Abortion Facility License Renewal Addendum
Form 3205, End Stage Renal Disease Facility License Renewal Addendum
Form 3057, Kidney Health Care Program Physician Assessment
Form 3642, ICF/IID Medicaid Bed Reallocation Application
Form 5007, CMBHS Access Request and User Agreement
Form 5303, WIC Vendor Materials Request
Form 5302, WIC General Information Feedback
Form 5301, WIC Director Orientation Training Registration