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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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Forms & Applications Quick Links
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Applications
- MDHHS-1171, Assistance Application
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.
- DHS-1929, Central Registry Clearance Request
- DHS-1929-SP, Central Registry Clearance Request
- DHS-1929-AR, Central Registry Clearance Request
- DHS-355, Participation Agreement For Michigan's Low Income Home Energy Assistance Program
- DHS-390, Adult Services Application
- DHS-390-AR, Adult Services Application
- DHS-390-SP, Adult Services Application
- DHS-1514, Application for State Emergency Relief
- DHS-1514-SP, Application for State Emergency Relief
- DHS-1661, Insurance Assistance Program (IAP)
- DHS-3243, Retroactive Medicaid Application
- DHS-3243-SP, Solicitud Para Medicaid Retroactivo
- DHS-4574-B, Asset Declaration Patient and Spouse
- DHS-4574, Medicaid Application Patient of Nursing Home
- DHS-4574-B-SP, Declaration De Bienes Paciente Y Esposo/A
- NSP-0938-B, Michigan Voter Registration Application Instructions
- MDHHS-1171, Assistance Application
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Adoption
- DHS-608, Personal Reference Letter
- DHS-1341-A, Request for Medical Subsidy for An Adopted Child
- DHS-1917, Adult Former Sibling Statement to Release Information to Adult Adoptee
- DHS-1918, Release of Information to Adult Adoptee by Brother/Sister as proxy for Deceased Parent
- DHS-1919, Parent's Consent/Denial to Release Information to Adult Adoptee
- DHS-1920, Release of Information Authorization Adult Adoptee
- DHS-1925, Request by Adult Adoptee for Identifying Information
- DHS-4746, Adoption Facilitator Clearing House Record
- MDHHS-5996, Legal Packet Supplemental-Adoption Assistance Verification
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Bureau of Hospitals and Behavioral Health Administration
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Adult
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Cash Assistance
- Refugee Family Self-Sufficiency Plan
Addressing employment related services 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. - MDHHS-1171, Assistance Application
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. - DHS-3243, Retroactive Medicaid Application
- DHS-3243-SP, Solicitud Para Medicaid Retoactivo
- DHS-4574-B, Asset Declaration Patient and Spouse
- DHS-4574, Medicaid Application Patient of Nursing Home
- DHS-4575-B-SP, Declaration De Bienes Paciente Y Esposo/A
- Refugee Family Self-Sufficiency Plan
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Child Care
- MDHHS-1171, Assistance Application
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.
- MDHHS-1171, Assistance Application
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Child Support
- DCH-0738, Notice of Intent to Claim Paternity Form
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. - DCH-0682, Affidavit of Parentage
When a child is born out of wedlock, parents can complete this form to voluntarily establish paternity (legal fatherhood) for their child. - e842, Child Support Response Form
If you are not 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. - DHS-1201, IV-D Child Support Services Application/Referral
If you are not receiving public assistance, apply for Child Support Services with this paper form. - DHS-1454, Office of Child Support Publication Order List
- DHS-1201-SP, Solicitud Para Servicios de Sostenimento de Ninos (IV-D)/Recomendacion
Si usted no está recibiendo asistencia pública, rellene este formulario para solicitar los servicios de Mantenimiento de Hijos
- DCH-0738, Notice of Intent to Claim Paternity Form
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Children's Protective Services
- DHS-990, Relative Notification Letter (Rev. 2-19a)
- DHS-990-SP, Relative Notification Letter (Spanish)
- DHS-990-AR, Relative Notification Letter (Arabic)
- DHS-3200, Report of Actual or Suspected Child Abuse or Neglect
Complete this form within 72 hours of calling in a suspicion of abuse or neglect - DHS-3200-SP, Report of Actual or Suspected Child Abuse or Neglect (Spanish)
- DHS-3200-AR, Report of Actual or Suspected Child Abuse or Neglect (Arabic)
- Multidisciplinary Team (MDT) Collaboration and Engagement Guide (DHS-Pub-1551)
- State of Michigan Sudden & Unexplained Child Death Scene Investigation Form
- MDHHS-6184, Request for Child Protective Services (CPS) for Records
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Earned Income Tax Credit (EITC)
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Emergency & Energy
- MDHHS-1171, Assistance 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. - DHS-355, Participation Agreement For Michigan's Low Income Home Energy Assistance Program
- DHS-1514-SP, Solicitud Para Ayuda de Emergencia del Estado
- DHS-1514, Application for State Emergency Relief
- MDHHS-1171, Assistance Applications
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Family Preservation Contractor Forms
- DHS-413, Family Preservation Programs Case Note
- MDHHS-6039, Family Preservation Contracted Universal Referral
- MDHHS-6058, Initial Prevention Plan
- MDHHS-6059, Updated Prevention Plan
- MDHHS-6060, Closing Prevention Plan
- MDHHS-6073, Family Preservation Job Aides for MDHHS-6058, MDHHS-6059, MDHHS-6060
- MDHHS-6116, Peer Recovery Coach (PRC) Referral
- MDHHS-6156, MiFamily Together Initial Prevention Plan
- MDHHS-6156-JA, MiFamily Together Initial Prevention Plan Job Aid
- MDHHS-6157, MiFamily Together Closing Prevention Plan
- MDHHS-6157-JA, MiFamily Together Closing Prevention Plan Job Aid
- MDHHS-6158, MiFamily Together Updated Prevention Plan
- MDHHS-6158-JA, MiFamily Together Updated Prevention Plan Job Aid
- MDHHS-6167, Direct Worker Survey
- MDHHS-6168, Referring Worker Survey
- MDHHS-6169, Family Survey
- MDHHS-6174, MiFamily Together Monthly Timesheet (Rev. 10-24)
- MDHHS-6175, MiFamily Together Follow-Up/Attempt Log (Rev. 10-24)
- Michigan FAST and Summary Sheet
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Food Assistance
- MDHHS-1171, Assistance 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.
- MDHHS-1171, Assistance Applications
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Foster Care
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Interstate Compact
- ICPC (Interstate Compact on the Placement of Children)
- DHS-3005, Recommendation and Assurance for Pre-Adoption and Requirement Certification
- DHS-3750, Sending State Priority Home Study Request
- DHS-4332, Interstate Compact Placement Request
- DHS-4333, Interstate Compact Report on Child's Placement Status
- DHS-4334, ICPC Financial/Medical Plan
- DHS-4335, Interstate Compact Checklist
- DHS-4336, Interstate Compact on the Placement of Children Placement Prescreening
- MDHHS-6132, ICPC Placement Assessment - Criminal History
- MDHHS-6142, Interstate Compact on the Placement of Children (ICPC) Placement Supervision Visit Tool
- ICJ (Interstate Commission for Juveniles)
For all ICJ related forms please visit https://www.juvenilecompact.org/forms. - MDHHS-5944, Interstate Commission for Juveniles (ICJ) Return Placement Invoice
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Legal
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Licensing - Adult Foster Care and Homes for the Aged
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Licensing - Child Care
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Licensing - Child Welfare
- CWL-4620, Corrective Action Plan
- CWL-4606, Child Welfare Licensing Placement Assistance Request
- CWL-4618, Disciplinary Action Unit Denial/Provisional/Revocation Checklist
- 3130 Packet Review Tool-Optional
- CWL-4006, Variance Request for CAP/CCI/COF Rules
- CWL-4607-CON, Chief Administrator Annual Assessment and Corrective Action Plan (Public and Contract Child Placing Agency)
- No Contract CPA Audit Workbook (Rev. 8-18)
- Adoption Contract CPA Audit Workbook
- Independent Living Contract CPA Audit Workbook (Rev. 8-18)
- TFC & ADO Contracts CPA Audit Workbook (Rev. 8-18)
- PAFC & ADO Contracts CPA Audit Workbook (Rev. 8-18)
- Child Welfare Licensing Form Request
- OCAL-PUB-31, Camper Management Manual
- CWL-0120A, North American Indian Tribal Affiliation Verification
- Court Operated Facility Rules Review Worksheets
- DHS-3200, Report of Actual or Suspected Child Abuse or Neglect
Complete this form within 72 hours of calling in a suspicion of abuse or neglect. - CWL-4603, Incident Accident Illness Death or Fire Report
- CWL-4614, Criminal History Record Information Challenge or Correction Form
- FPBR Spreadsheet for CPA
- MDHHS-5612, Verification of Tribal Foster Home/Approved Relative Safety Requirements
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Native American Affairs (NAA) and Native American Outreach Services (NAOS)
- DHS-120, American Indian/Alaska Native (AI/AN) Court Hearing Notification
- DHS-120-A, ICWA/MIFPA Multiple Document Mailing Cover Sheet
- DHS-120-B, Transfer To Tribal Agency/Court
- DHS-120-C, American Indian/Alaska Native Child Welfare Cultural Plan
- DHS-121-A, American Indian/Alaska Native Descendant Child Welfare Case Notification
- Indian Child Welfare Act Performance Checklist
- DHS-382, Native American Outreach Services Referral
- DHS-383, Native American Outreach Services Contract Log (Rev. 3-21)
- DHS-384, Native American Outreach Services Packet Cover (Rev. 3-21)
- DHS-385, Native American Outreach Service Report (Rev. 3-21)
- MDHHS-5598, American Indian/Alaska Native Child/Parent Ancestry Verification (Rev. 3-24)
- MDHHS-5763, Annual Business Plan
- MDHHS-5993, American Indian/Alaska Native (AI/AN) Tribal Affiliation Verification - Foster Home (Rev. 9-22)
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Relative Licensing
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Medical Services
- DCH-1426, Health Coverage & Help Paying Costs Application
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. - DHS-PUB-280, Reporting Changes When, How & What to Report
- DHS-PUB-280-SP, Reporting Changes When, How & What to Report (Spanish)
- DHS-PUB-783, MDHHS Can Help with Temporary Assistance
- DHS-8-A, Irrevocable Funeral Contract Certification
- DHS-114A, Deductible Report
- DHS-114A-SP, Informe de Deducible
- DHS-3243, Retroactive Medicaid Application
- DHS-3243-SP, Solicitud Para Medicaid Retroactivo
- DHS-4574-B, Asset Declaration Patient and Spouse
- DHS-4574, Medicaid Application Patient of Nursing Home
- DHS-4574-B-SP, Declaration De Bienes Paciente Y Esposo/A
- DCH-1426, Health Coverage & Help Paying Costs Application
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Other
- DCH-1183, Authorization to Disclose Protected Health Information
- DHS-18, Request for a Hearing
- DHS-18-A, Hearing Request Withdrawal
- DHS-848, Certification of Translation for Non-English Speaking Applicants or Recipients
- NSP-0938-B, Voter Registration Application and Michigan Driver License/Personal Identification Card Address Change Form
- NSP-0938-B-SP, 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
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Prevention Services Forms
- DHS-1327, Prevention Services - Family Goals and Progress Tracker
- DHS-1328, Referral for Prevention Services
- MDHHS-5973, Home Visiting/SafeCare Program Referral
- MDHHS-6053, Families First Prevention Services Act (FFPSA) Notification For Tribes With Title IV-E Agreement
- MDHHS-6054, Families First Prevention Services Act (FFPSA) Notification For Tribes With No Title IV-E Agreement
- DHS-1555-HV, Authorization to Release Confidential Information - Home Visiting Programs
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Safe Delivery
- DHS-4819, Voluntary Medical Background Form
If the surrendering parent wishes to provide information about their medical background, this information would assist with the newborn's care. - DHS-4819-SP, Forma Voluntaria de Antecedentes Medicos para un Recien Nacido Entregado
La Forma Voluntaria de Antecedentes Médicos para un Recién Nacido Entregado es llenada por el Proveedor de Servicios de Emergencia. - DHS-4820, Voluntary Release for Adoption
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. - DHS-4820-SP, Entega Voluntaria Para Adopcion De Un Recien Nacido Por Parte De Un Padre
- DHS-4819, Voluntary Medical Background Form
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Substance Use Disorder Family Support Program Forms
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Vital Records
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Volunteer