Arkansas Department of Human Services Forms

This form is used for conducting a MFP assessment and collecting personal history information in the state of Arkansas.

This form is used for the transition and risk mitigation plan related to the Managed Facility Program (MFP) in Arkansas.

This form is used for monthly risk mitigation reporting in Arkansas.

This form is used for providing general professional recommendations in Arkansas.

This Form is used for creating a detailed plan of care for individuals receiving demonstration services in Arkansas.

This document is used for giving consent to discuss a Managed long-term services and supports (MLTSS) case with the Medicaid for Adults program in Arkansas.

This Form is used for the Money Follows the Person Transition Housing program in Arkansas. It allows individuals to apply for assistance in transitioning from long-term care facilities to community-based housing.

This form is used for reporting the transition goods and services in Arkansas.

This document is used to request a tier level change in the state of Arkansas.

This form is used for requesting demonstration services and exercising freedom of choice in the state of Arkansas.

This form is used for referring individuals in Arkansas to receive personal care services.

This form is used for participants in the Money Follows the Person (MFP) program in Arkansas to understand their rights and responsibilities.

This checklist is used for monitoring and tracking MFP/ITM activities in the state of Arkansas.

This document is used for verifying child care arrangements in Arkansas. It is typically required when applying for certain state assistance programs.

This document is used for verifying the earnings of individuals who are starting new employment in the state of Arkansas.

This document is for obtaining a certification in health and safety training in Arkansas under the Child Care Development Block Grant (CCDBG) program.

This document is used for applying for a license for a child placement agency in the state of Arkansas.

This form is used for reporting positive cases of a certain disease or condition, and the Pcc List is a list of these reported cases in the state of Arkansas.

This document is used for applying for a child welfare agency license specifically for a residential facility in Arkansas. It outlines the necessary requirements and information needed to obtain the license.

This form is used for individuals who are authorized to sign in on behalf of CCDF (Child Care Development Fund) programs in the state of Arkansas.

This document is used for conducting pandemic screening in the state of Arkansas. It outlines the necessary protocols and procedures to identify and respond to potential outbreaks and ensure public health and safety.

This document is a Spanish form used to apply for SNAP benefits, healthcare assistance, and Tea/RCA in Arkansas.

This form is used for applying for Medicare Savings for Qualified Beneficiaries (ArSeniors, QMB, SMB, and QI-1) in the state of Arkansas. It helps individuals who meet certain income and asset requirements to receive assistance with their Medicare costs.

This Form is used to create an irrevocable income trust in the state of Arkansas. It is a legal document that allows a person to transfer assets into a trust for the benefit of beneficiaries, while also maintaining control over the income generated by those assets.

This form is used for applying for SNAP (Supplemental Nutrition Assistance Program), health care benefits, and Tea/RCA (Transitional Employment Assistance/Responsible Choice Act) benefits in Arkansas.

This Form is used for applying for Snap, Health Care, and Tea-Rca benefits in Arkansas for Marshallese individuals.

This Form is used for authorizing the inclusion of an adult's information in the Arkansas Adult Maltreatment Central Registry.

This form is used for releasing information about a CHC family member in Arkansas.

This form is used for requesting a criminal record check from the FBI in the state of Arkansas.

This document is for the DDS Ombudsman Program in Arkansas and is used for initial contact purposes.

This form is used for reporting third-party resources or medical insurance in the state of Arkansas.

This form is used for reporting social information of children in Arkansas. It helps in assessing their needs and providing appropriate support and interventions.

This Form is used for assigning rights related to Tea and Medicaid applications in Arkansas.

This form is used for physicians in Arkansas to assess the eligibility of a Tefra Waiver. The Tefra Waiver allows individuals with disabilities to receive Medicaid services while residing in a specialized nursing facility.

This form is used for the annual renewal notice required under the Tax Equity and Fiscal Responsibility Act (TEFRA) in Arkansas.

This form is used for summarizing resources available at behavioral health agencies in Arkansas.

This document provides information about the available respite programs and services in Arkansas for individuals of all ages who are in need of temporary caregiver relief.