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 1061, Class D Pharmacy License Exemption Request
Form 1022, Authorization to Disclose Information Including Protected Health Information for Referral to Another Agency or Organization ES
Form 3645, Monthly Medicaid Occupancy Report
Form 3900, Application for Certificate of Deafness for Tuition Waiver ES
Form 3236, Licensed Chemical Dependency Counselor Licensure by Reciprocity Application
Form 3093, KHC Travel Claim for Home Dialysis and Kidney Transplant Patients
Form 3038, Children’s Autism Program Family Cost Share Attestation Worksheet
Form 3033, Hemophilia Assistance Program (HAP) Application ES
Form 3012, Verification of Eligibility ES
Form 2870, Permission to Disclose Protected Health and Other Confidential Information
Form 2603, STAR Kids Individual Service Plan (ISP) Narrative ES
Form 2247, Interest List Contact Notification ES
Form 2097, Provider Contract Assignment Notification ES
Form 2124, Supported Home Living or Community Support Transportation Log ES
Form 2128, 120 Day Notice ES