U.S. Department of Health & Human Services
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Public Use Forms by Number

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Form
Number
Title
Revision
Date
Form
Link
 

Health and Human Services (HHS)

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

   
PHS-398 Public Health Service – Includes Research Career Awards and Institutional National Research Service Awards
08/12
Adobe PDF Icon
PHS-416-1 Application for an Individual National Research Service Award Fellowship
Instructions
08/12
PHS-416-5 Research Fellowship Activation Notice
08/12
Adobe PDF Icon
PHS-416-7 Termination Notice NRSA
08/12
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PHS-416-9 Application for PHS Individual National Research Service Continuation Award
Instructions
08/12
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PHS-2590 Application for Continuation of a PHS Grant
08/12
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PHS-3734 Official Statement Relinquishing Interest and Rights in a PHS Research Grant
06/09
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PHS-6031 National Research Service Award
08/12
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PHS-6031-1 Annual National Research Service Award
08/12
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PHS-6315 Assurance of Compliance by Sub-Award Recipients
05/14
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PHS-6349 Annual Report on Possible Research Misconduct
10/15
Adobe PDF Icon
 

 

Substance Abuse and Mental Health Services Administration (SAMHSA)

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

 

Indian Health Service

   
IHS-810 IHS Authorization for Release of Information
04/09
Adobe PDF Icon
IHS-843-1A Order for Health Services
07/14
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IHS-912-1 Request for Restriction(s)
04/09
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IHS-912-2 Request for Revocation of Restriction(s)
04/09
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IHS-913 Request for an Accounting of Disclosures
04/09
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IHS-917 Request for Correction/Amendment of Protected Health Information
04/09
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IHS-963 Request for Confidential Communication by Alternative Means or Alternate Location
04/09
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Content created by Program Support Center (PSC)
Content last reviewed on January 23, 2015