South Carolina Department of Health and Human Services Forms

This document is used for enrolling vendors and clearinghouses in the Trading Partner Agreement program in South Carolina.

This document is used for authorizing electronic funds transfers in the state of South Carolina. It allows individuals or businesses to set up automatic payments or direct deposits.

This document is used for filing a complaint regarding the privacy of health information in South Carolina.

This Form is used for applying to the Medically Indigent Assistance Program in South Carolina. It is for individuals who require medical assistance but cannot afford it.

This form is used for applying for Covid-19 limited benefits in South Carolina under the Department of Health and Human Services (DHHS).

This form is used for revoking authorization to disclose health information in South Carolina.

This form is used for authorizing the disclosure of health information in South Carolina.

This document is an addendum to the DHHS Form 3400E application and is used specifically for tuberculosis (TB) referrals in South Carolina.

This form is used for applying for TEFRA (Tax Equity and Fiscal Responsibility Act) services in South Carolina through the Department of Health and Human Services (DHHS). TEFRA services provide Medicaid coverage for children with disabilities.

This document is an application form for the South Carolina Nurse Aide Training Program. It is used by individuals who are interested in becoming a certified nurse aide in South Carolina.

This document is a letter sent to providers in South Carolina to request revalidation of their enrollment. Revalidation is necessary to ensure that providers continue to meet the state's requirements for participation in healthcare programs.

This form is used for providing additional information for select Medicaid programs in South Carolina. (Spanish version)