U.S. Department of Health and Human Services Forms

This form is used for retirees and individuals eligible for COBRA coverage to choose a pre-payment option for their healthcare costs.

This Form is used for making changes to employee information such as address, contact details, or job title.

This type of document includes agreements between patients and healthcare providers. It outlines the terms and conditions of treatment, including consent, payment, and confidentiality. The forms are used to ensure clear communication and protect both the patient and the provider.

This checklist is used during a bedside shift report to ensure all necessary information is communicated between healthcare providers at the patient's bedside.

This Form is used for recording quantitative liver function test results. It helps healthcare professionals monitor the function of the liver.

This Form is used to collect information related to the Affordable Care Act and its provisions. The form helps individuals provide the necessary details for assessing their eligibility and enrolling in health insurance plans under the Affordable Care Act.

This document is a worksheet used by surveyors to take notes during inspections or surveys.

This Form is used for reporting the completion of a project. It includes information such as project details, accomplishments, key deliverables, challenges faced, and recommendations for future projects.

This document provides a growth chart for boys from birth to 36 months. It includes percentiles for both length-for-age and weight-for-age, ranging from the 5th to the 95th percentile.

This document provides information on available transportation resources specifically designed for older adults to maintain their mobility independence. It includes a list of choices and options for accessing transportation services.

This document provides a chart that displays the ranks and insignia of the different branches of the United States uniformed services.

This type of document is a test that measures leg strength and overall fitness. It involves repeatedly standing up from a chair in 30 seconds.

This document is used to certify the death of an individual and provide details about the cause and circumstances of their death. It is an important record for legal, medical, and statistical purposes.

This Form is used for reporting the readiness standards of the Commissioned Corps Annual Physical Fitness Test (APFT). It helps assess the physical fitness of members in the Commissioned Corps.

This Form is used for enrolling in the Head Start Child and Adult Care Food Program (CACFP).

This form is used to withdraw a request for an administrative law judge hearing or to review a dismissal.

This Form is used for observing and evaluating the kitchen and food service areas in healthcare facilities to ensure compliance with relevant regulations and standards.

This Form is used for conducting a family interview for CMS services.

This fact sheet provides information and statistics about teen dating violence. It highlights the importance of understanding and identifying signs of unhealthy relationships among teenagers.

This form is used for applying and reporting end stage renal disease (ESRD) services. It is designed for healthcare providers to apply for ESRD certification and submit survey and certification reports.

This form is used for filing a complaint regarding civil rights discrimination. It provides a way for individuals to report incidents of discrimination based on race, color, national origin, disability, sex, or religion.

This form is used for individuals to request corrections, amendments, or deletions of their records held by the Department of Health and Human Services. It allows individuals to update their personal information and ensure the accuracy of their records.

This form is used for evaluating the effectiveness of commissioned officers in the US Public Health Service.

This Form is used for joining the NIH Leave Bank program and making donations to the program.

This form is used for requesting and obtaining authorization for a leave of absence for commissioned officers in the Public Health Service.

This form is used for requesting personnel actions for commissioned officers.

This form is used for reporting the dental examination of applicants to the Public Health Service Commissioned Corps.

This form is used to ensure compliance with regulations set by the Department of Health and Human Services.

This form is used for submitting a nomination for an individual to receive an honor award.