Forms & Applications
Forms and applications listed here are only a portion of those available. Visit your local MDHHS Office for forms or applications not available online.
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Applications
- Assistance Application (DHS-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
- Medicaid Application Patient of Nursing Home - DHS-4574
- Asset Declaration Patient and Spouse - DHS-4574-B
- 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 (DHS-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 (DHS-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
- 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
- Relative Search Information - DHS-988 (WORD)
- Relative Search Information(Busqueda de Informacion de Parentesco) - DHS-988-SP
- Relative Response Form - DHS-989 (WORD)
- Relative Notification Form Letter for CPS and Foster Care - DHS-990 (WORD)
- INFORMACIÓN SOBRE ABUSO O DESCUIDO DE NIÑOS REAL O SOSPECHADO - DHS-3200-SP
- 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 (Arabic Version) - DHS-3200-AR
- State of Michigan Sudden & Unexplained Child Death Scene Investigation Form
Emergency & Energy
- Assistance Application (DHS-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 (DHS-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
Licensing - Child Care
No articles at this time.
Licensing - Child Welfare
- Chief Administrator Annual Assessment and Corrective Action Plan (Public and Contract Child Placing Agency) - CWL-4607-CON
- IL Contract CPA Audit Sheet
- No Contract CPA Audit Sheet
- IL Contract CPA Employee File Review
- ADO Contract CPA Employee File Review
- Licensing Record Clearance Request - CWL-1326-IA
- Adoption Contract CPA Audit Sheet
- PAFC & ADO Contracts CPA Audit Sheet
- PAFC & ADO Contracts CPA Employee File Review
- TFC & ADO Contracts CPA Audit Sheet
- No Contract CPA Employee File Review
- TFC & ADO Contracts CPA Employee File Review
- Child Welfare Licensing Form Request
- Camper Management Manual - OCAL PUB-31
- Court Operated Facility Rules Review Worksheets
- Licensing Rules for Foster Family Homes and
Foster Family Group Homes for Children - CWL-PUB-10
- 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.
- Foster Home Reference Questionnaire - OCAL-3739
- Medical Emergency Care Authorization - OCAL-3978
- Emergency Telephone Numbers - OCAL-4234
- Incident Accident Illness Death or Fire Report - CWL-4603
Native American Affairs (NAA) & Indian Outreach Services (IOS)
- American Indian/Alaska Native (AI/AN) Child Case 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
- Notice to Canadian Indian Tribe Concerning Court Proceeding DHS-121
- American Indian/Alaska Native Descendant Child Welfare Case Notification DHS-121-A
- Indian Child Welfare Act Performance Checklist
- Indian Outreach Services Referral IOS 382
- Indian Outreach Services Contract Log IOS 383
- Indian Outreach Services Packet Cover IOS 384
- Indian Outreach Service Report Cover IOS 385
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 on Your Assistance Case - DHS Pub-280
- Reportando Cambios - 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
- 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
