Forms

Title Effective Date
DHB-1061 Checklist for Child Medical Evaluation (CME) Reporting Sep 18, 2023 03:25 PM
DHB-2039 PHP Notification of Nursing Facility Level of Care Dec 07, 2022 09:55 AM
DHB-2040 Tribal and Indian Health Services Jan 07, 2021 12:00 AM
DHB-2040B Tribal and Indian Health Services Sep 23, 2021 11:40 AM
DHB-2043 Third Party Recovery Accident Information Form Sep 17, 2019 03:40 PM
DHB-2044ia Medicaid Credit Balance Report Jul 07, 2023 07:56 AM
DHB-2045 Instructions for Completing Medicaid Credit Balance Report Jul 07, 2023 07:45 AM
DHB-2050 Voluntary Request to Terminate Medicaid Apr 03, 2023 08:05 AM
DHB-2055 Reimbursement for Medical Transportation May 17, 2022 04:25 PM
DHB-2056 Purchased Medical Transportation Costs May 09, 2022 09:05 AM
DHB-2190 Internal Inspection Report Aug 15, 2023 01:45 PM
DHB-2191 Designation of Control Officer for FRR/Beer Reports Aug 15, 2023 01:48 PM
DHB-2192 SSA Training Form - County Staff and County Contract Staff Aug 15, 2023 01:49 PM
DHB-2193 Memorandum of CAP Waiver Enrollment Oct 21, 2020 10:25 AM
DHB-2194 IRC Rules Handout Aug 15, 2023 01:50 PM
DHB-2195 Documentation of Annual Security Training Confidentiality Form – County Staff Aug 15, 2023 01:52 PM
DHB-2196 Documentation of Annual Security Training - Shred Contractor Training Aug 15, 2023 01:53 PM
DHB-2197 FTI Record Keeping Log Aug 15, 2023 01:54 PM
DHB-2198 Log for Destruction of the FRR/BEER Reports Aug 15, 2023 02:00 PM
DHB-2199 Documentation of the Visitation Logs Aug 15, 2023 02:02 PM
DHB-2200 Access Control Log Aug 15, 2023 02:04 PM
DHB-2201 Confidentiality of Safeguard Data Aug 15, 2023 02:05 PM
DHB-2202 Beneficiary Notice Aug 15, 2023 02:06 PM
DHB-3051-ia Form and Instructions - Request for Independent Assessment for Personal Care Services - Attestation of Medical Need Jul 09, 2021 03:40 PM
DHB-4037 Disability Determination Transmittal Aug 08, 2017 03:20 PM
DHB-5001N Notice on the Use of Social Security Numbers Jun 09, 2009 03:20 PM
DHB-5001N_sp AVISO SOBRE EL USO DE LOS NÚMEROS DE SEGURO SOCIAL Feb 04, 2022 09:50 AM
DHB-5002 Important Notice About Your Medicaid or Special Assistance Approval Sep 27, 2021 01:30 PM
DHB-5002sp-ia Lea Este Importante Aviso Sobre Medicail o la Asistencia Especial Aviso de Aprobacion Jun 01, 2021 10:20 AM
DHB-5003 Important Notice About Your Medicaid Approval Notice Feb 20, 2024 03:01 PM