Lynne A. Valenti
Cabinet Secretary

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Below you will find the selected forms and/or publications for this order. You will need to indicate the quantity you want to receive in the box next to the document number. After you have entered the quantity, click "Update" in the previous box. If you wish to remove a form or publication, simply click on the link that states "Delete." Once you have entered the quantity for each form or publication, click the "Proceed" button at the bottom.

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CopiesEdit the Number of CopiesDocument NumberDocument NameDelete
1EditBH-11aAdult SUD Initial Outcome ToolDelete
1EditOS-950Recipient Forms: Title XIX Medical Transportation ReimbursementDelete
1EditCCSPathways to Professional Development - Career Lattice Application FormDelete
1EditCPS-508Reference Form - Adoption / Foster / Kinship CareDelete
1EditSE408CPApplication and Agreement for Services - Custodial Parent and/or CaretakerDelete
1EditBRO/CPS4Mandatory Reporting of Child Abuse & Neglect BrochureDelete
1EditBRO/EA16Medical Assistance for Children and Families: IHS SpecificDelete
1EditBH-11cAdult SUD Discharge Outcome Tool Delete
1EditBRO/CPS1Child Protection Services BookletDelete
1EditBH-17Prevention - Accreditation ApplicationDelete
1EditBH-11eAdult MH Update Outcome ToolDelete
1EditEA-265Request for Long-Term Care or Home Community Based Services Waiver AssistanceDelete
1EditCPSProvider Mileage RequestDelete
1EditCPS-533Adoption Registry FormDelete
1EditPosterReportable Disease List PosterDelete
1EditBRO/DSS3Administrative Hearings BrochureDelete
1EditMSTitle XIX Non-Emergency Transportation Payment Authorization FormDelete
1EditEA-347Application for Social Security NumberDelete
1EditBRO/EACommunity Action Agency HandoutDelete
1EditEA-307SNAP Exit FormDelete
1EditCPSICPC Financial and Medical PlanDelete
1EditPAPrior Authorization Forms: Private Duty Nursing & Extended Home Health ServicesDelete
1EditDSS-W9W-9 FormDelete
1EditBH-063rd Party Release of Information (ROI)Delete
1EditBRO/DCS6Voluntary Paternity Establishment Handbook and FormDelete
1EditBRO/CCS3Registration & Licensure of Child Care EnvironmentsDelete
1EditBRO/EA14Medical Assistance for Children and FamiliesDelete
1EditCPS-549Request for Screening for Substantial Reports of Abuse and Neglect (unregistered family day care providers ONLY)Delete
1EditCPSBackground Information for Voluntary Termination of Parental RightsDelete
1EditCPS-522Request for PaymentDelete
1EditEA-297Energy Assistance ApplicationDelete
1EditCPSPlacement Resource Monthly Reporting Form Ages 0-4Delete
1EditEA-269Child Care Expense Billing InformationDelete
1EditBH-08Mental Health - IMPACT ApplicationDelete
1EditSE-405Application for Income Withholding Only ServiceDelete
1EditEA-298Weatherization ApplicationDelete
1EditBH-11bAdult SUD Update Outcome ToolDelete
1EditDSS-ORFI-831Estate Recovery Notification of Death FormDelete
1EditEA-301SNAP ApplicationDelete
1Edit Recipient Forms: HIPAA Privacy Consent FormDelete
1EditBRO/MS1Medical Assistance Program Recipient HandbookDelete
1EditBRO/MS3Well-Child Care BrochureDelete
1EditEA-301Economic Assistance ApplicationDelete
1EditBRO/CPS3Safe Havens BrochureDelete
1EditENERGYVendor Information: Direct DepositDelete
1EditBRO/DSS9DSS HandbookDelete
1EditCPSIndependent Living Program Education and Training Voucher Delete
1EditEA-305Boarding School-Institution DocumentationDelete
1EditBRO/EA10SNAP for StudentsDelete
1EditBRO/DSS6Filing a Discrimination Complaint Brochure and FormDelete
1EditBRO/EA5Medicare Savings Program BrochureDelete