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Public Use Forms by Number

We are committed to ensuring that all HHS forms on this Web site are fully accessible to individuals with disabilities in accordance with Section 508 of the Rehabilitation Act. If you have any difficulty viewing any page with adaptive technology, please contact the webmaster for this site, or the HHS Forms Coordinator.

Documents on the HHS Web sites are available in PDF format. These forms are accessible to users using Microsoft Active Accessibility (MSAA), JAWs for Windows screen reading software as well as Dragon Naturally Speaking Voice Recognition Software. Adobe provides their Acrobat Reader software as a free download.

 

Form
Number
Title
Revision
Date
Form
Link
 

Health and Human Services (HHS)

  
HHS-419Clearance of Employees for Separation or Transfer
08/14
Adobe PDF Icon
HHS-520Request for Approval of Outside Activity
01/06
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HHS-521Annual Report of Outside Activity
01/06
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HHS-568Procedures for Submission of Final Invention Statement
08/12
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HHS-690Assurance of Compliance
01/09
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HHS-691Request for Special Pay for Physicians and Dentists
10/06
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HHS-697Foreign Activities Questionnaire
04/02
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HHS-719Request for Copy of the Record(s) in the Case File
09/05
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HHS-720Request for Copy of Record(s): Third –Party With the Individual Appellant’s Consent
08/05
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HHS-721Individual Appellant’s Consent to Third-Party for Copies for the Individual Appellant’s Record(s)
08/05
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HHS-722Request for Substitution of Party Upon Death of Party
08/05
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HHS-723Waiver of Right to an Administrative Law Judge (ALJ) Hearing
08/05
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HHS-724Request to Correct, Amend, or Delete a Record (s)
08/05
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HHS-725Request for Administrative Law Judge (ALJ) to Review Dismissal by the Qualified Independent Contractor
08/05
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HHS-727Extension Request to File a Request for an Administrative Law Judge (ALJ) Hearing
08/05
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HHS-728Filing of New Evidence
08/05
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HHS-729Response to Notice of Hearing
08/05
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HHS-730Withdrawal of Request for an Administrative Law Judge (ALJ) Hearing (Spanish)
08/05
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HHS-731Withdrawal of Waiver of Right to an Administrative Law Judge (ALJ) Hearing
08/05
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HHS-733Identity Verification
08/05
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HHS-734Payment Information Report
09/05
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HHS-T-001Response to Notice of Hearing
08/05
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Public Health Service (PHS)

  
PHS-398Public Health Service – Includes Research Career Awards and Institutional National Research Service Awards
08/12
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PHS-416-1Application for an Individual National Research Service Award Fellowship
Instructions
08/12
PHS-416-5Research Fellowship Activation Notice
08/12
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PHS-416-7Termination Notice NRSA
08/12
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PHS-416-9Application for PHS Individual National Research Service Continuation Award
Instructions
08/12
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PHS-2590Application for Continuation of a PHS Grant
08/12
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PHS-3734Official Statement Relinquishing Interest and Rights in a PHS Research Grant
06/09
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PHS-6031National Research Service Award
08/12
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PHS-6031-1Annual National Research Service Award
08/12
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PHS-6315Assurance of Compliance by Sub-Award Recipients
05/14
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PHS-6349Annual Report on Possible Research Misconduct
10/14
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Substance Abuse and Mental Health Services Administration (SAMHSA)

  
SMA-162Application for Certification to Use Opioid Drugs in a Treatment Center
01/03
SMA-167Notification of Intent to Use Opioid Drugs for Maintenance and Treatment
 00/00
SMA-172SAMHSA Application for Peer Grant Review Exp 06/04
 

 

Indian Health Service

  
IHS-810IHS Authorization for Release of Information04/09Adobe PDF Icon
IHS-843-1AOrder for Health Services07/14Adobe PDF Icon
IHS-912-1Request for Restriction(s)04/09Adobe PDF Icon
IHS-912-2Request for Revocation of Restriction(s)04/09Adobe PDF Icon
IHS-913Request for an Accounting of Disclosures04/09Adobe PDF Icon
IHS-917Request for Correction/Amendment of Protected Health Information04/09Adobe PDF Icon
IHS-963Request for Confidential Communication by Alternative Means or Alternate Location04/09Adobe PDF Icon

Content created by Assist. Sec./Administration - Program Support Center
Content last reviewed on October 31, 2014