Forms

Title Effective Date
dhhs-1000-DSB-instructions: DSB/Authorization to Disclose Health Information Instructions Sep 22, 2009 04:20 PM
dhhs-1000-ia: DSB Authorization to Disclose Health Information Nov 19, 2010 04:25 PM
dhhs-1000-sp-ia DSB/ Authorization to Disclose Health Information -Spanish Jun 24, 2019 09:00 AM
dhhs-3531 dsb-0910-ia: Conference Authorization Oct 01, 2008 01:35 PM
dsb-0197-ILR-ia: ILR Request for Residence Modification Nov 19, 2010 12:40 PM
dsb-0197-ILR-instructions: ILR/Request for Residence Modification Instructions May 27, 2009 02:55 PM
dsb-0311: DSB/Employee Administration Request Form Jul 25, 2011 03:05 PM
dsb-0502-ia: DSB/Travel Authorization and Training Registration Jul 22, 2015 03:10 PM
dsb-0502-instructions: DSB/Travel Authorization and Training Registration Instructions May 24, 2012 03:15 PM
dsb-0503-ia: DSB/Driver Service Billing Form Mar 14, 2012 03:20 PM
dsb-0511: DSB/Pharmacy Claim Form Jun 17, 2015 03:20 PM
dsb-0511-instructions: DSB/Pharmacy Claim Form Instructions Jun 07, 2015 03:25 PM
dsb-0525-DSB-instructions: DSB/ DSB Accounts Receivable/ Refund Instructions Aug 24, 2011 03:30 PM
dsb-0525-ia: DSB/DSB Accounts Receivable/ Refund Mar 18, 2011 03:35 PM
dsb-0612-ia: DSB/Staff Approved to Authorize Services, Approve Authorizations, and/or Approved Invoices Apr 15, 2009 03:35 PM
dsb-0613-VR-ia: VR/Assignment of Reimbursement Nov 19, 2010 03:40 PM
dsb-0613-VR-instructions: VR/Assignment of Reimbursement Instructions May 27, 2009 03:40 PM
dsb-0950-ia: DSB/Verification of Items Received Nov 19, 2010 03:45 PM
dsb-0950-ia-instructions: DSB/Verification of Items Received Instructions May 27, 2009 03:50 PM
dsb-1010-ia: Blind Registry/Registrant Data Form Feb 14, 2014 03:55 PM
dsb-2001-ia: MED.EYE/Application for Eye Care Certification Oct 21, 2013 04:00 PM
dsb-2001-instructions: MED.EYE/Application for Eye Care Certification Instructions Sep 20, 2010 04:05 PM
dsb-2007-ia: DSB/Evaluation with Video Magnification (Closed Circuit Television) May 27, 2009 04:05 PM
dsb-2007-instructions DSB/ Evaluation with Video Magnification (Closed Circuit Television) Instructions Jun 24, 2007 09:25 AM
dsb-2031-ia: MED.EYE/Letter to Accompany Mailed Application Nov 19, 2010 04:10 PM
dsb-2032-ia: MED.EYE/Notification of Need for Additional Information Nov 19, 2010 04:15 PM
dsb-2032-instructions: MED.EYE/Notification of Need for Additional Information Instructions May 27, 2009 04:20 PM
dsb-2033-ia: MED.EYE/Notification of Eligibility Status Nov 22, 2011 04:20 PM
dsb-2033-instructions: MED.EYE/Notification of Eligibility Status Instructions May 27, 2009 04:25 PM
dsb-2202-ia: DSB/Report of Eye Examination Jun 17, 2016 04:25 PM