DHS

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Forms & Documents

Office of Long Term Care Forms

2018 Long-Term Services & Support Application
2018 Long-Term Services & Services Application (Spanish)
Long-Term Services & Supports Program Information
Long-Term Serives & Supports Program Information (Spanish)

Forms

Title Type Posted Date
Silver Haired Legislative Delegate Petition Form PDF 01/03/2020
AAS-9511 Change of Client Status Form PDF 08/01/2019
Important Notice Form PDF 05/13/2019
24 Hour Contact Information Form PDF 05/12/2019
DHS-4000 Authorized to Disclose Health Info-Release of Info Form PDF 05/11/2019
DHS-4000 Release of Info Authorization - Spanish Edition PDF 05/11/2019
DHS-8504 Start Service Form PDF 05/10/2019
DHS-8505 Informed Consent PDF 05/09/2019
DHS-8506 MFP Assessment and Personal History Form PDF 05/08/2019
DHS-8507 Checklist of Clients Rights Form PDF 05/07/2019
DHS-8508 Statement of Rights & Responsibilities of MFP Participants Form PDF 05/06/2019
DHS-8510 Demonstration Services Freedom of Choice Form PDF 05/05/2019
DHS-8511 Transition Risk Plan Form PDF 05/04/2019
DHS-8512 Risk Mitigation Monthly Form PDF 05/03/2019
DHS-8520 General Professional Recommendations Form PDF 05/02/2019
DHS-8521 Demonstration Services Plan of Care Form PDF 05/01/2019
DHS-8523 Housing Information Form PDF 04/30/2019
MediMaide Checklist (Need copy of Prescriptions) Form PDF 04/29/2019
Consent to Discuss Form PDF 04/28/2019
Tier Level Request Form PDF 04/27/2019
Transition Goods and Services Form PDF 04/26/2019
Helping Hands Respite Programs form PDF 02/19/2019
APS-0001 Request for Adult Maltreatment Registry Information DOC 09/12/2016

Information & Forms

Title Type Posted Date
Silver Haired Legislative Delegate Petition Form PDF 01/03/2020
Silver Haired Legislative Session Guidelines PDF 01/03/2020

Resources

Title Type Posted Date
Infant Mental Health Therapist Provider Training PDF 08/25/2020
Dealing with the Effects of Trauma PDF
Arkansas Department of Human Services
Arkansas Department of Human Services

Arkansas Department
of Human Services
(501) 682-1001

TTY: 1-800-285-1131 or dial 711 for Arkansas Relay Service

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