TX HHS Form H1854. Affidavit for Unauthorized Use of Electronic Benefit Transfer (EBT) Benefits
This form is used when a SNAP household in Texas discovers that someone has accessed and spent their EBT (Lone Star Card) benefits without permission. It is an official affidavit required by the Texas Health and Human Services Commission (HHSC) before replacement benefits can be considered.
TX HHS Form 3262. Licensed Chemical Dependency Counselor Intern Supervised Work Experience Documentation
Form 3262 is the official document used in Texas to verify and report the supervised work experience hours completed by a Licensed Chemical Dependency Counselor (LCDC) Intern.
TX HHS Form 3599. Habilitation Service Provider Orientation/Supervisory Visits
Texas Form 3599 is an official document used by providers within the Texas Health and Human Services Commission (HHSC) programs, specifically CLASS (Community Living Assistance and Support Services) and CFC (Community First Choice).
TX HHS Form 1582. Consumer Directed Services Responsibilities
Form 1582 explains the core responsibilities of everyone involved in the Consumer Directed Services (CDS) option in Texas. Unlike agency-based care, CDS gives an individual (or their legally authorized representative) the authority to hire, train, and supervise their own service providers.
TX HHS Form H1826. Case Information Release
Form H1826 is a document used in Texas when an individual wants to authorize the Health and Human Services Commission (HHSC) to share information from their case record with another person or organization.
TX HHS Form 6109. Special Care Facility Incident Report
Form 6109, officially titled Special Care Facility Incident Report, is a mandatory document used by special care facilities to report serious events such as abuse, neglect, fires, injuries, medical emergencies, and other incidents affecting patients or staff.
TX HHS Form 3697. Transfer Agreement
The Transfer Agreement (Form 3697) establishes a formal understanding between hospitals and skilled nursing facilities to ensure the continuity of patient care.
PS Form 1094. Request for Post Office Box Key or Lock Service
This form — PS Form 1094, “Request for Post Office Box Key or Lock Service” — is used whenever a PO Box holder needs to obtain additional keys, replace worn or broken keys, or request lock-related services from the United States Postal Service.
Form LIC 702. Child's Preadmission Health History - Parent/Authorized Representative Report - California
The “Child’s Preadmission Health History – Parent/Authorized Representative Report” (Form LIC 702) is a standard document required by licensed child care centers across California.
Form LIC 9158. Telecommunications Device Notification
The “Telecommunications Device Notification” form is a short but legally significant document used in California community care facilities.