Forms & Publications
Forms and applications listed here are only a portion of those available. Visit your local MDHHS Office for forms or applications not available online.
To view or print PDF files, you will need Adobe Acrobat Reader. If you do not already have Reader installed on your computer, it is available free of charge from Adobe's web site.
Applications
- Assistance Application (MDHHS-1171)
A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that you'll need to print and complete the application, and then take it to your local MDHHS office.
- Central Registry Clearance Request - DHS-1929
- Participation Agreement For Michigan's Low Income Home Energy Assistance Program - DHS-355
- Adult Services Application - DHS-390
- Application for State Emergency Relief - DHS-1514
- Application for State Emergency Relief - DHS-1514-SP
- Insurance Assistance Program (IAP) - DHS-1661
- Retroactive Medicaid Application - DHS-3243
- Solicitud Para Medicaid Retroactivo - DHS-3243-SP
- Asset Declaration Patient and Spouse - DHS-4574-B
- Medicaid Application Patient of Nursing Home - DHS-4574
- Declaration De Bienes Paciente Y Esposo/A - DHS-4574-B-SP
- Voter Registration Application and Michigan Driver License/Personal Identification Card Address Change Form - NSP-0938-B
- Solicitud de Registración del Votante y Licencia de Manejar de Michigan/Instrucciones de la Forma para Cambiar su Dirección en su Tarjeta de Identificación Personal - NSP-0938B-SP
Adoption
- Personal Reference Letter - DHS-608
- Request for Medical Subsidy for An Adopted Child - DHS-1341-A
- Adult Former Sibling Statement to Release Information to Adult Adoptee - DHS-1917
- Release of Information to Adult Adoptee by Brother/Sister as proxy for Deceased Parent - DHS-1918
- Parent's Consent/Denial to Release Information to Adult Adoptee - DHS-1919
- Release of Information Authorization Adult Adoptee - DHS-1920
- Request by Adult Adoptee for Identifying Information - DHS-1925
- Adoption Facilitator Clearing House Record, DHS-4746 Adoption Facilitator Clearing House Record, - DHS-4746
Cash Assistance
- Refugee Family Self-Sufficiency Plan
Addressing employment related service needs to help families become self-supporting. With the assistance and input of the refugee client, the refugee contractor must complete this plan within 30 days of receiving the referral, and send a completed and signed copy to the local MDHHS office within 5 days of completion.
- Assistance Application (MDHHS-1171)
A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that you'll need to print and complete the application, and then take it to your local MDHHS office.
- Retroactive Medicaid Application - DHS-3243
- Solicitud Para Medicaid Retroactivo - DHS-3243-SP
- Asset Declaration Patient and Spouse - DHS-4574-B
- Medicaid Application Patient of Nursing Home - DHS-4574
- Declaration De Bienes Paciente Y Esposo/A - DHS-4574-B-SP
Child Care
- Assistance Application (MDHHS-1171)
A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that you'll need to print and complete the application, and then take it to your local MDHHS office.
Child Support
- Notice of Intent to Claim Paternity Form - DCH-0738
Before a child is born, a putative father can file a Notice of Intent to Claim Paternity. By doing so, this person will be presumed to be the father of the child unless the mother denies that the claimant is the father.
- Affidavit of Parentage - DCH-0682
When a child is born out of wedlock, parents can complete this form to voluntarily establish paternity (legal fatherhood) for their child.
- Child Support Response Form - e842 If you are receiving public assistance, complete this form to provide additional information to your caseworker.
- Apply for Child Support Online If you are not receiving public assistance, apply for Child Support Services online.
- IV-D Child Support Services Application/Referral - DHS-1201 If you are not receiving public assistance, apply for Child Support Services with this paper form.
- Office of Child Support Publication Order List - DHS-1454
- Solicitud Para Servicios de Sostenimento de Ninos (IV-D)/Recomendacion - DHS-1201-SP Si usted no está recibiendo asistencia pública, rellene este formulario para solicitar los servicios de Mantenimiento de Hijos
Children's Protective Services
- DHS-990 Relative Notification Letter (rev.2-19a)
- DHS-990-SP Relative Notification Letter (Spanish) (rev.2-19)
- DHS-990-AR Relative Notification Letter (Arabic) (rev.2-19)
- Report of Actual or Suspected Child Abuse or Neglect - DHS-3200
Complete this form within 72 hours of calling in a suspicion of abuse or neglect.
- Report of Actual or Suspected Child Abuse or Neglect (Spanish) - DHS-3200-SP
- Report of Actual or Suspected Child Abuse or Neglect (Arabic) - DHS-3200-AR
- State of Michigan Sudden & Unexplained Child Death Scene Investigation Form
Emergency & Energy
- Assistance Application (MDHHS-1171)
A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that you'll need to print and complete the application, and then take it to your local MDHHS office.
- Participation Agreement For Michigan's Low Income Home Energy Assistance Program - DHS-355
- Solicitud Para Ayuda de Emergencia del Estado - DHS-1514-SP
- Application for State Emergency Relief - DHS-1514
Food Assistance
- Assistance Application (MDHHS-1171)
A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that you'll need to print and complete the application, and then take it to your local MDHHS office.
Interstate Compact
- Interstate Compact on Juveniles Petition for Requisition to Return a Runaway Juvenile - DHS-1908 ICJ Form A
- Detention Order - DHS-1909
- Recommendation and Assurance for Pre-Adoption and Requirement Certification - DHS-3005
- Interstate Compact on Juveniles Out of State Travel Permit and Agreement to Return - DHS-3034 ICJ Travel Permit
- Interstate Compact on Juveniles Requisition for Escapee/Absconder/Juvenile Charged Delinquent (Rendition Amendment) - DHS-3036 ICJ Juvenile Rights
- Interstate Compact on Juveniles Consent for Voluntary Return by Runaway, Escapee or Absconder - DHS-3037 ICJ Form III
- Interstate Compact on Juveniles Parole or Probation Investigation Request - DHS-3038 ICJ Form IV
- Interstate Compact on Juveniles Parolee/Probationer Report to Receiving State - DHS-3039 ICJ Form V
- Interstate Compact on Juveniles Application for Services and Waiver - DHS-3040 ICJ Form 1A-VI
- Sending State Priority Home Study Request - DHS-3750
- Interstate Compact Placement Request - DHS-4332
- Interstate Compact Report on Child's Placement Status - DHS-4333
- ICPC Financial/Medical Plan - DHS-4334
- Interstate Compact Checklist - DHS-4335
- Interstate Compact on the Placement of Children Placement Prescreening - DHS-4336
- MDHHS-5849, Michigan ICPC Article III.c Supplemental Questions (COVID-19)
Licensing - Child Welfare
- Corrective Action Plan, CWL-4620
- Child Welfare Licensing Placement Assistance Request, CWL-4606
- Disciplinary Action Unit Denial/Provisional/Revocation Checklist, CWL-4618
- 3130 Packet Review Tool-Optional
- Chief Administrator Annual Assessment and Corrective Action Plan (Public and Contract Child Placing Agency) - CWL-4607-CON
- Variance Request for CPA/CCI/COF Rules - CWL-4006
- Independent Living Contract CPA Audit Workbook 8-17-18
- Adoption Contract CPA Audit Workbook
- No Contract CPA Audit Workbook 8-17-18
- TFC & ADO Contracts CPA Audit Workbook 8-30-18
- PAFC & ADO Contracts CPA Audit Workbook 8-28-18
- Child Welfare Licensing Form Request
- Court Operated Facility Rules Review Worksheets
- Camper Management Manual - OCAL PUB-31
- North American Indian Tribal Affiliation Verification - CWL-0120A
- Report of Actual or Suspected Child Abuse or Neglect - DHS-3200
Complete this form within 72 hours of calling in a suspicion of abuse or neglect.
- Incident Accident Illness Death or Fire Report - CWL-4603
- Criminal History Record Information Challenge or Correction Form (CWL 4614)
- FPBR Spreadsheet for CPA
- Verification of Tribal Foster Home Safety Requirements - MDHHS-5612
Native American Affairs (NAA) and Native American Outreach Services (NAOS)
- American Indian/Alaska Native (AI/AN) Court Hearing Notification DHS-120
- ICWA/MIFPA Multiple Document Mailing Cover Sheet DHS-120-A
- Transfer To Tribal Agency/Court DHS-120-B
- American Indian/Alaska Native Child Welfare Cultural Plan DHS-120-C
- American Indian/Alaska Native Descendant Child Welfare Case Notification DHS-121-A
- Indian Child Welfare Act Performance Checklist
- Native American Outreach Services Referral DHS-382
- Native American Outreach Services Contract Log DHS-383 (rev. 3-21)
- Native American Outreach Services Packet Cover DHS-384 (rev. 3-21)
- Native American Outreach Service Report DHS-385 (rev. 3-21)
- American Indian/Alaska Native Child Ancestry Verification MDHHS-5598
- Annual Business Plan MDHHS-5763
Medical Services
- Health Coverage & Help Paying Costs Application - DCH-1426
The Michigan Department of Health and Human Services offers several medical assistance programs. Each program covers different groups of people and each program has different eligibility requirements.
- Reporting Changes When, How & What to Report - DHS-Pub-280
- Reporting Changes When, How & What to Report (Spanish) - DHS-Pub-280-SP
- MDHHS Can Help with Temporary Assistance - DHS Pub-783
- Irrevocable Funeral Contract Certification - DHS-8-A
- Deductible Report - DHS-114A
- Informe de Deducible - DHS-114A-SP
- Retroactive Medicaid Application - DHS-3243
- Solicitud Para Medicaid Retroactivo - DHS-3243-SP
- Asset Declaration Patient and Spouse - DHS-4574-B
- Medicaid Application Patient of Nursing Home - DHS-4574
- Declaration De Bienes Paciente Y Esposo/A - DHS-4574-B-SP
Other
- Authorization to Disclose Protected Health Information - DCH-1183
- Request for Hearing - DHS-18
- Hearing Request Withdrawal - DHS-18-A
- Certification of Translation for Non-English Speaking Applicants or Recipients - DHS-848
- Voter Registration Application and Michigan Driver License/Personal Identification Card Address Change Form - NSP-0938-B
- Solicitud de Registración del Votante y Licencia de Manejar de Michigan/Instrucciones de la Forma para Cambiar su Dirección en su Tarjeta de Identificación Personal - NSP-0938B-SP
Safe Delivery
- Voluntary Medical Background Form - DHS-4819
If the surrendering parent wishes to provide information about their medical background, this information would assist with the newborn's care.
- Forma Voluntaria de Antecedentes Medicos para un Recien Nacido Entregado - DHS-4819-SP La Forma Voluntaria de Antecedentes Médicos para un Recién Nacido Entregado es llenada por el Proveedor de Servicios de Emergencia.
- Voluntary Release for Adoption - DHS-4820
The Voluntary Release for Adoption of a Surrendered Newborn by Parent form is a written affirmation that the surrendering parent voluntary released their parental rights to their newborn child.
- Entega Voluntaria Para Adopcion De Un Recien Nacido Por Parte De Un Padre - DHS-4820-SP
