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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 3763, Description of the Representative Sample Selection
Form 3762, Room Size Variance
Form 3707, Fire Report for Long Term Care Facilities
Form 3705, Application for Plan Review for an Assisted Living Facility
Form 3704, Application for Plan Review for an ICF/IID Facility
Form 3703, Application for Plan Review for a Nursing Facility
Form 3702, Application for Plan Review for an Adult Day Care Facility
Form 3700, Application for Plan Review for a Prescribed Pediatric Extended Care Center (PPECC)
Form 3697, Transfer Agreement
Form 3696, Expression of Intermediary Preference
Form 3695, Prospective Owner Intentions Regarding Medicare Certification
Form 3604, Ownership Transfer Affidavit
Form 3599, Habilitation Service Provider Orientation/Supervisory Visits
Form 3100, Information Regarding Authorized Electronic Monitoring for Assisted Living Facility ES
Form 3026, Random Sample Review of Nursing On-call and/or Deceased Individual Required Submission of Documentation
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