Local Districts Social Service Forms

  • DOH-4441 – Medicaid Presumptive Eligibility (PE) for Children Screening Form (PDF)
  • DOH-5244 – Medicaid Presumptive Eligibility for Pregnant Women Screening Checklist (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)