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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 5150, Family Service Plan ES
Form 5160, Individualized Written Rehabilitation Plan (IWRP)
Form 5164, Individualized Written Rehabilitation Plan (IWRP)
Form LSC, Lone Star Card
Form H5019-MBIC, Hardship Waiver Approved (Medicaid Buy-In for Children) ES
Form H4851-P, Notice of Administrative Disqualification Hearing
Form H1122-A, Medicaid Information - Client Rights/Responsibilities
Form H1017-A, Notice of Benefit Denial or Reduction - Client Rights/Responsibilities
Form H1000-A, Notice of Application
Form 8710, Criminal History Statement
Form 8708, Criminal History Disclosure
Form 8670, Daily Physical Activity Log
Form 8669, Daily Food Log
Form 8667, Individual Volunteer Statement
Form 8666, Volunteer Orientation Agreement
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