Local Districts Social Service Forms
- DOH-4441 – Medicaid Presumptive Eligibility (PE) for Children Screening Form (PDF)
- DOH-5224 – Medicaid Presumptive Eligibility for Pregnant Women Screening Checklist (PDF)
- DOH-5298 – Request for Assessment – Spousal Impoverishment (PDF)
- LDSS-3113 – Acknowledgement of Hysterectomy Information (PDF)
- LDSS-3113s – Acknowledgement of Hysterectomy Information (Spanish) (PDF)
- LDSS-3134 – Sterilization Consent Form (PDF)
- LDSS-3134s – Sterilization Consent Form (Spanish) (PDF)
