Local Districts Social Service Forms

• DOH-4441 - Medicaid Presumptive Eligibility (PE) for Children Screening Form (PDF, 59KB, 2pg.)
• DOH-5244 - Medicaid Presumptive Eligibility for Pregnant Women Screening Checklist (PDF, 79KB, 2pg.)
• LDSS-3113 - Acknowledgement of Hysterectomy Information (PDF, 42KB, 1pg.)
• LDSS-3113s - Acknowledgement of Hysterectomy Information (Spanish) (PDF, 27KB, 1pg.)
• LDSS-3134 - Sterilization Consent Form (PDF, 85KB, 1pg.)
• LDSS-3134s - Sterilization Consent Form (Spanish) (PDF, 122KB, 1pg.)