Nebraska Department of Health and Human Services Forms
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Form MILTC-64 "Application for Nebraska Medicaid for Aged and Disabled" - Nebraska
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Form MILTC-53 "Application for Medicaid and Insurance Affordability Programs (Financial Assistance)" - Nebraska
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24 votes
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Form HHS-81 "Application for Amendment" - Nebraska
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74 votes
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285 KB
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Form MILTC-51 "Step 2: Extra Persons in Household Current Job and Income Information" - Nebraska
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34 votes
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242 KB
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Form EA-117 "Application for Economic Assistance Benefits" - Nebraska
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11 votes
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5 MB
20 pages
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Form CRED-914 "Alternative Compliance Request" - Nebraska
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59 votes
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256 KB
1 page
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Form CRED-0915 (A) "Authorization for Release of Information" - Nebraska
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51 votes
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239 KB
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Form CRED-0600 "Report of Law Enforcement Contact" - Nebraska
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44 votes
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166 KB
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Form CRED-0810 "Immunization Record" - Nebraska
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98 votes
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213 KB
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Form MILTC-1400 "Respite Subsidy Application" - Nebraska
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(4.8 / 5)
57 votes
Size:
110 KB
3 pages
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Formulario EA-117-S "Solicitud De Beneficios De Asistencia Economica" - Nebraska (Spanish)
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(4.3 / 5)
6 votes
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4 MB
20 pages
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Form HHS-92 (55092) "Application for Certified Copy of Death Certificate" - Nebraska
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70 votes
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136 KB
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"Work Verification Request" - Nebraska
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16 votes
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82 KB
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"Emergency Assistance Verification Request Form" - Nebraska
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14 votes
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93 KB
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"Accident Witness Statement" - Nebraska
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11 votes
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125 KB
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"Tip Ledger" - Nebraska
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8 votes
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8 KB
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"Request Form for Catastrophic Illness Leave" - Nebraska
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25 votes
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11 KB
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"Amendment to an Application Not Including Household Member" - Nebraska
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32 votes
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278 KB
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"Director Orientation Review: Statements of Understanding" - Nebraska
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23 votes
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372 KB
8 pages
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"Fire and Tornado Drill Record Form" - Nebraska
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34 votes
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319 KB
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"Economic Assistance Self-employment Ledger" - Nebraska
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22 votes
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15 KB
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Instructions for "Change of Ownership of an Existing Child Care Program" - Nebraska
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(4.7 / 5)
25 votes
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66 KB
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![Form MILTC-64 "Application for Nebraska Medicaid for Aged and Disabled" - Nebraska](https://data.templateroller.com/pdf_docs_html/2049/20495/2049533/form-miltc-64-application-for-nebraska-medicaid-for-aged-and-disabled-nebraska.png "Form MILTC-64 "Application for Nebraska Medicaid for Aged and Disabled" - Nebraska")
![Form MILTC-53 "Application for Medicaid and Insurance Affordability Programs (Financial Assistance)" - Nebraska](https://data.templateroller.com/pdf_docs_html/2049/20495/2049534/form-miltc-53-application-for-medicaid-and-insurance-affordability-programs-financial-assistance-nebraska.png "Form MILTC-53 "Application for Medicaid and Insurance Affordability Programs (Financial Assistance)" - Nebraska")
![Form HHS-81 "Application for Amendment" - Nebraska](https://data.templateroller.com/pdf_docs_html/474/4740/474063/form-hhs-81-application-amendment-nebraska.png "Form HHS-81 "Application for Amendment" - Nebraska")
![Form MILTC-51 "Step 2: Extra Persons in Household Current Job and Income Information" - Nebraska](https://data.templateroller.com/pdf_docs_html/2049/20495/2049535/form-miltc-51-step-2-extra-persons-in-household-current-job-and-income-information-nebraska.png "Form MILTC-51 "Step 2: Extra Persons in Household Current Job and Income Information" - Nebraska")
![Form EA-117 "Application for Economic Assistance Benefits" - Nebraska](https://data.templateroller.com/pdf_docs_html/2049/20493/2049387/form-ea-117-application-for-economic-assistance-benefits-nebraska.png "Form EA-117 "Application for Economic Assistance Benefits" - Nebraska")
![Form CRED-914 "Alternative Compliance Request" - Nebraska](https://data.templateroller.com/pdf_docs_html/1842/18423/1842375/form-cred-914-alternative-compliance-request-nebraska.png "Form CRED-914 "Alternative Compliance Request" - Nebraska")
![Form CRED-0915 (A) "Authorization for Release of Information" - Nebraska](https://data.templateroller.com/pdf_docs_html/1842/18423/1842372/form-cred-0915-form-a-authorization-release-information-nebraska.png "Form CRED-0915 (A) "Authorization for Release of Information" - Nebraska")
![Form CRED-0600 "Report of Law Enforcement Contact" - Nebraska](https://data.templateroller.com/pdf_docs_html/1842/18423/1842370/form-cred-0600-report-law-enforcement-contact-nebraska.png "Form CRED-0600 "Report of Law Enforcement Contact" - Nebraska")
![Form CRED-0810 "Immunization Record" - Nebraska](https://data.templateroller.com/pdf_docs_html/1842/18423/1842374/form-cred-0810-immunization-record-nebraska.png "Form CRED-0810 "Immunization Record" - Nebraska")
![Form MILTC-1400 "Respite Subsidy Application" - Nebraska](https://data.templateroller.com/pdf_docs_html/82/824/82418/form-miltc-1400-respite-subsidy-application-nebraska.png "Form MILTC-1400 "Respite Subsidy Application" - Nebraska")
![Formulario EA-117-S "Solicitud De Beneficios De Asistencia Economica" - Nebraska (Spanish)](https://data.templateroller.com/pdf_docs_html/2049/20493/2049386/formulario-ea-117-s-solicitud-de-beneficios-de-asistencia-economica-nebraska-spanish.png "Formulario EA-117-S "Solicitud De Beneficios De Asistencia Economica" - Nebraska (Spanish)")
![Form HHS-92 (55092) "Application for Certified Copy of Death Certificate" - Nebraska](https://data.templateroller.com/pdf_docs_html/373/3738/373835/form-hhs-92-55092-application-certified-copy-death-certificate-nebraska.png "Form HHS-92 (55092) "Application for Certified Copy of Death Certificate" - Nebraska")
!["Work Verification Request" - Nebraska](https://data.templateroller.com/pdf_docs_html/2078/20783/2078359/work-verification-request-nebraska.png ""Work Verification Request" - Nebraska")
!["Emergency Assistance Verification Request Form" - Nebraska](https://data.templateroller.com/pdf_docs_html/2078/20783/2078357/emergency-assistance-verification-request-form-nebraska.png ""Emergency Assistance Verification Request Form" - Nebraska")
!["Accident Witness Statement" - Nebraska](https://data.templateroller.com/pdf_docs_html/1842/18423/1842355/accident-witness-statement-nebraska.png ""Accident Witness Statement" - Nebraska")
!["Tip Ledger" - Nebraska](https://data.templateroller.com/pdf_docs_html/1797/17970/1797022/tip-ledger-nebraska.png ""Tip Ledger" - Nebraska")
!["Request Form for Catastrophic Illness Leave" - Nebraska](https://data.templateroller.com/pdf_docs_html/1842/18423/1842356/request-form-catastrophic-illness-leave-nebraska.png ""Request Form for Catastrophic Illness Leave" - Nebraska")
!["Amendment to an Application Not Including Household Member" - Nebraska](https://data.templateroller.com/pdf_docs_html/1842/18423/1842368/amendment-to-an-application-not-including-household-member-nebraska.png ""Amendment to an Application Not Including Household Member" - Nebraska")
!["Director Orientation Review: Statements of Understanding" - Nebraska](https://data.templateroller.com/pdf_docs_html/1842/18423/1842369/director-orientation-review-statements-understanding-nebraska.png ""Director Orientation Review: Statements of Understanding" - Nebraska")
!["Fire and Tornado Drill Record Form" - Nebraska](https://data.templateroller.com/pdf_docs_html/1842/18423/1842376/fire-and-tornado-drill-record-form-nebraska.png ""Fire and Tornado Drill Record Form" - Nebraska")
!["Economic Assistance Self-employment Ledger" - Nebraska](https://data.templateroller.com/pdf_docs_html/2078/20783/2078358/economic-assistance-self-employment-ledger-nebraska.png ""Economic Assistance Self-employment Ledger" - Nebraska")
![Instructions for "Change of Ownership of an Existing Child Care Program" - Nebraska](https://data.templateroller.com/pdf_docs_html/1842/18423/1842371/instructions-change-ownership-an-existing-child-care-program.png "Instructions for "Change of Ownership of an Existing Child Care Program" - Nebraska")
