To apply for Health Care, go to the online DHS benefits portal or download the paper DHS Application (Spanish).To discuss another person’s case, please download the Authorization to Obtain or Release Health Care Information form and send the completed form to Imaging Center 4, PO Box 2027 Cedar Rapids, IA 52406 or fax to 515-564-4017.For information on how to apply for Nursing Facility Medicaid visit the Long Term Care page. HS-3191 Monthly Racial and Ethnic Data myCOMPASS PA is a mobile app for people living in Pennsylvania who have applied for or receive state benefits. Client Complaint, Complaint Under Civil Rights Act of 1964 English Application (HS-0169) - English Addendum - English Instructions - English Instructions Addendum Withdrawal of Civil Rights Complaint (Arabic) HIPAA Authorization for Release of Medical/Health Information to a 3rd Party (Spanish) (HS-2939sp) - Instructions HIPAA Authorization for Release of Medical/Health Information to a 3rd Party (Arabic) (HS-2939a) - Instructions Families First Program Waiver of Hearing and Disqualification Consent Agreement (Spanish) (HS-3113SP) - Spanish Instructions, Family Assistance Self-Employment Calendar - Instructions, Family Assistance Fax Cover Sheet (English) (HS-3457) - Instructions Apply In Person. HIPAA Authorization for Release of Medical/Health Information (Somali) (HS-2557s) - Instructions Provider Reimbursement and Operations Management Information System (PROMISe) is a web-based application for registered providers. Family Assistance Fax Cover Sheet (Spanish) (HS-3457sp) - Instructions – (If applying for SNAP only, an incomplete application can be accepted as long as it contains your name, address, and signature). English / Spanish / Arabic / Somali, Consolidated Appeal Request (HS-3058) - Instructions General Authorization for Release of Information to the TDHS to a 3rd Party - (Spanish) Instructions Monthly Racial and Ethnic Data, Home TN-ELDS Documentation Form hs-3131 SSBG Annual Program Evaluation - instructions HIPAA Authorization for Release of Medical/Health Information (Arabic) (HS-2557a) - Instructions Criminal Background Check Transfer (HS-3299) - Instructions Subscribe to receive email updates from the Department of Human Services program offices. hs-3480 SSBG Missed Appointment Log - instructions DHS Online Services COMPASS. Affidavit Request for SNAP Replacement Due to Power Outage (HS-3003) Instructions, Affidavit Request for SNAP replacement Due to Power Outage (HS-3003) Spanish Instructions. If you are applying for SNAP (food stamp) benefits, the documents listed below may be needed to complete the application process. Please Select a Link to Continue. Application to Renew a License To Operate A Child Care Agency (HS-2012) - Instructions These replacement benefits are available for existing SNAP recipients who: Individuals requesting replacement benefits need to sign an affidavit and send it to DHS using the File Upload tool, available here: https://fileupload.dhs.tn.gov/. Home and Community Services Information System (HCSIS) is a web-based application that serves as the operating system for all Department of Human Services program offices that support the home and community-based services programs and Medicaid waivers. Parent/Guardian Authorization For The Tennessee Department Of Education Or Local Education Agency To Release School Attendance Records - (Spanish) These centers coordinate care for people with Medicaid. Welcome to the Family Assistance Online Application! Withdrawal of Civil Rights Complaint (Somali) hs-3117 Application for Social Services Block Grant (SSBG) Services - instructions Consolidated Appeal Request in Spanish (HS-3058SP) - Spanish Instructions, Withdrawal of Appeal for Fair Hearing (HS-2908) - Form Instructions, Adult Day Care Criminal/Juvenile History & State Registry Review Disclosure (HS-2680) - Instructions
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