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 1129, Fire Suppression Authority Notification
Form 1127, Fire Marshal/State Fire Marshal Notification
Form 1126, Physician's Assessment
Form 1125, Resident's Request to Remain in Facility
Form 1084, Certification for Warrants Lost, Destroyed, Stolen or Not Received ES
Form 1026, Verification of Railroad Retirement Benefits
Form 1020, Acknowledgement of Responsibility for Reporting Abuse, Neglect and Exploitation and Reasonable Suspicion of Crime
Form 0067, Consent by Roommate for Authorized Electronic Monitoring ES
Form 0066, Request for Authorized Electronic Monitoring
Form 0065, Information Regarding Authorized Electronic Monitoring for Nursing Facilities ES