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Electronic DSHS FormsYou may download some DSHS forms. These are provided only if a DSHS program requests forms to be available electronically for public use. DSHS forms are available for electronic completion in different software; however, all DSHS forms below are available as Adobe Acrobat PDF files. This means you can open, view, and print each form. To open, view, and print PDF forms, you need to download the free Adobe Acrobat Reader. Additionally, you may download the free Shana Informed filler to electronically complete Shana forms below. On opening your first Shana form, you will be asked to enter a registration key. Please enter 32064015014070671 (you only need to enter this once). If you do not have Microsoft Word, download Microsoft Viewer. This allows you to open, view, and print Word forms. If asked for a password when using Microsoft Word forms, select the cancel button to continue. Passwords prevent changes being made to the form's content. We do our best to ensure the links below are accurate; but, if you find a link which does not work, please contact Forms and Records Management. Search tip: To help find a specific form by number or key word, hold down the Ctrl key and type the F key. This will call up the "Find" dialogue box. Enter the number or title word(s) and select "Find Next." |
| Form Number | Form Title | Software |
| 01-110 | Protective Payee Report | Word | ||
| 01-110A | Protective Payee Periodic Social Services Report | Word | ||
| 01-110C | Protective Payee Report Continuation | Word | ||
| 01-192 | Referral for Mental Health/Substance Abuse Assessment (EPSDT) (Healthy Kids) | Shana | ||
| 01-210 | Transmittal of Client Funds from the Protective Payee | Shana | ||
| 02-305 | Service Episode Record (Children's Administration) | Word | ||
| 02-327 | JRA Work Request (Juvenile Rehabilitation Administration) | Word | ||
| 02-516 | Adult Family Home Resident Personal Belongings Inventory | Word | ||
| 02-528 | Fair Hearing Withdrawal | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 02-556 | Request for Exception to Policy (ETP) for Use of Restrictive Procedures (DDD) | Word | ||
| 02-573 | Background check Identification Verification (Office of Deaf and Hard of Hearing) | Word | ||
| 02-574 | Application for Advisory Body Appointment | Word | ||
| 02-578 | TED Monthly Client Contact Report (Division of Vocational Rehabilitation) | Word | ||
| 02-586 | Temporary Employment Hours Tracking Log | Word | ||
| 02-587 | CLIP/CSO Communication | Word | ||
| 03-076 | Employee Personal Property Damage/Loss Claim | Word | ||
| 03-077 | Release of All Claims | Word | ||
| 03-133 | Employee/Volunteer Personal Incident Report | Word | ||
| 03-366 | Service Verification and Attendance Record (Children's Administration) | Word | ||
| 03-372 | Process Improvement Request (PIR) (Division of Developmental Disabilities) | Word | ||
| 03-387 | Notice of Privacy Practices for Client Confidential Information | Word | ||
| PDF Translations: Albanian, Amharic, Arabic, Bengali, Bulgarian, Burmese, Cambodian, Chinese, Haitian-Creole/French-Creole, Farsi, French, German, Hindi, Hmong, Hungarian, Ilocano, Indonesian, Italian, Japanese, Karen, Korean, Kurdish, Laotian, Oromo, Polish, Nepali, Portuguese, Punjabi, Romanian, Russian, Samoan, Somali, Serbo-Croatian, Spanish Word, Spanish, Swahili, Tagalog, Thai, Tibetan, Tigrigna, Turkish, Ukrainian, Urdu, Vietnamese | ||||
| 03-387A | Notice of Privacy Practices for Client Confidential Information without Acknowledgement | |||
| 03-389 | Witness Statement | Word | ||
| 03-389A | Assault Benefits Program Witness Statement | Word | ||
| 03-391 | Employee Report of Resident/Client Assault (RCW 72.01.045, RCW 74.04.790) | Word | ||
| 03-394 | Supervisor's Review of Employee Report of Resident/Client Assault | Word | ||
| 03-430 | Alternative Work Schedule Request and Review | Word | ||
| 04-220 | Family Ancestry Chart (Children's Administration) | Word | ||
| PDF Translations: Laotian Spanish Word, Spanish | ||||
| 04-220A | Indian Heritage Questionnaire (Division of Developmental Disabilities | Word | PDF Translations: Spanish Word, Spanish, | |
| 04-416 | DBHR Target Data Elements Assessment/Admission Set-Up | Word | ||
| 04-416A | DBHR Target Data Elements Discharge or ADATSA Closure | Word | ||
| 04-417 | DBHR Target Detox Short Form | Word | ||
| 04-418 | DBHR Target Treatment Activities | Word | ||
| 04-419 | DBHR Target Client Support Activities (Non-Treatment) | Word | ||
| 04-420 | DBHR Target Facility Staff | Word | ||
| 04-423 | DBHR Target Change of Circumstances | Word | ||
| 04-432 | Treatment Plan and Change Report (DASA) | Word | ||
| 04-433 | ADATSA/Adult Assessment | Word | ||
| 04-433B | ADATSA/Adult Assessment ADATSA Treatment Eligibility | Word | ||
| 04-434 | Division of Developmental Disabilities - Tell us how we are doing! | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 04-436 | DBHR Target Group Treatment Activities | Word | ||
| 04-437 | DBHR Target Agency Support Activities (Non-Treatment) | Word | ||
| 04-438 | DBHR Target Group Support Activities | Word | ||
| 04-442 |
Nursing Home Credit Balance Report
PDF Instructions |
Excel | ||
| 04-443 |
Character, Competence, and Suitability Evaluation for Unsupervised Access to Adult
PDF Instructions |
Word | ||
| 04-444 | Waiting List - First Contact | Word | ||
| 05-013 | Request for Hearing | Word | ||
| PDF Translations:, Cambodian, Chinese, Ilocano, Japanese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 05-180 | Federal Grant Application (Office of Juvenile Justice) | Shana | ||
| 05-180B | State Grant Application (Office of Juvenile Justice) | Shana | ||
| 05-180C | Juvenile Detention Alternatives Initiative Grant Application (Office of Juvenile Justice) | Shana | ||
| 05-180D | Federal Grant Application - CJJC | Shana | ||
| 05-203 | Foster Care Administrative Review (Children's Administration) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Samoan, Spanish, Vietnamese | ||||
| 05-210 | Exception Request (DCFS) | Word | ||
| 05-210A | Attachment A Exceptional Cost Foster Care (Children's Administration) | Word | ||
| 05-218 | LIST Examination Application | Word | ||
| 05-220 | Children's Administration Fee Waiver | Word | ||
| 05-234 | Unit of Local Government (ULG) Application (JRA) | Word | ||
| 05-234A | Unit of Local Government (ULG) Application Continuation (JRA) | Word | ||
| 05-239 | DCFS Social Worker Monthly Progress Report | Word | ||
| 05-246 | Notice of Action Exception to Rule (Home and Community Services) | Word | ||
| PDF Translations: Cambodian, Chinese, Farsi, Hungarian, Japanese, Korean, Kurdish, Laotian, Polish, Punjabi, Russian, Somali, Spanish, Tagalog, Ukrainian, Urdu, Vietnamese | ||||
| 06-110 | Client and Billing Summary | Word | Shana | |
| 06-123 | Nursing Assistant Training and Testing Reimbursement | Word | ||
| 06-124 | Cost of Care Adjustment Request (Division of Developmental Disabilities | Word | ||
| 06-125 | Residential Allowance Request | Excel | ||
| 06-126 | MHCP Multiple Premium Payment Adjustment | Shana | ||
| 06-159 | Psychologist and Sex Offender Treatment Provider Invoice (DDD) | Word | ||
| 06-160 | Adoption Support Monthly Counseling Billing | Word | ||
| 07-042B | Self-Employment Income Report | Word | ||
| PDF Translations: Cambodian, Chinese, Hmong, Korean, Laotian, Portuguese, Punjabi, Russian, Somali, Spanish, Vietnamese, | ||||
| 07-066 | WCCC Award/Change Letter | Shana | Word | |
| PDF Translations: Amharic, Arabic, Bulgarian, Burmese, Cambodian, Chinese, Farsi, French, French-Haitian Creole, Indonesian, Korean, Laotian, Mongolian, Nuer, Oromo, Portuguese, Portuguese, Punjabi, Russian, Serbo-Croatian, Somali, Spanish, Swahili, Tigrigna, Trukese, Vietnamese | ||||
| 07-075 |
In-Home/Relative Provider |
Word | ||
| PDF Translations: Russian, Spanish | ||||
| 07-076 | Request for Information (Working Connections Child Care) | Word | ||
| PDF Translations: Amharic, Arabic, Burmese, Cambodian, Chinese, Creole, French, Hmong, Korean, Japanese, Laotian, Mongolian, Nepali, Nuer, Oromo, Portuguese, Punjabi, Romanian, Russian, Somali, Spanish, Swahili, Tagalog, Trukese, Ukrainian, Vietnamese | ||||
| 07-078 |
Self-Employment Worksheet |
Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Punjabi, Russian, Somali, Spanish, Vietnamese | ||||
| 07-079 | Mileage Reimbursement (Childrens Administration) | Shana | Word | |
| PDF Translations: Vietnamese | ||||
| 07-081 | Participation Reimbursement Form | Shana | ||
| 07-086 | Notice of Discharge (Division of Developmental Disabilities) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 07-087 | Eligibility Checklist for DDD State Supplementary Payments (SSP) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 07-089 | ADSA Individual Provider Safety Training Attestation of Completion | Word | ||
| 08-225 | Participant Performance Reporting | Shana | ||
| 09-004C | Voluntary Placement Agreement for Child or Youth with Developmental Disabilities | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 09-013 |
Vendor Affidavit of Lost, Stolen, or Destroyed Warrant |
Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese | ||||
| 09-048 | Core Provider Agreement | Word | ||
| 09-052 | Affidavit of Forged Endorsement | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 09-097 | Record of Official Actions (Juvenile Rehabilitation Administration) | Word | ||
| 09-341 | Order of Parole Conditions (Juvenile Rehabilitation Administration) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 09-453 | Guardianship Petition (Indian Child) | Shana | ||
| 09-474 | Petition for Relinquishment and Termination of Parent - Child Relationship (Indian Child) | Shana | ||
| 09-508 | Waiver of Statute of Limitations Defense | Shana | ||
| PDF Translations: Arabic, Cambodian, Chinese, German, Ilocano, Laotian, Portuguese, Punjabi, Romanian, Russian, Spanish, Tagalog, Vietnamese | ||||
| 09-520 | Request for Conference Board | Shana | ||
| PDF Translations: Arabic, Cambodian, Chinese, Hebrew, Serbo-Croatian, Somali, Spanish, Russian, Vietnamese | ||||
| 09-536 | Inquiry to Bureau of Indian Affairs (BIA) | Word | ||
| 09-537 | Notice to Non-Federally Recognized or Canadian Indian Tribe or Band RE: Court Hearing | Shana | ||
| 09-539 | Inquiry to Indian Tribe, Band, or Nation | Word | ||
| 09-539A | Inquiry to Indian Tribe, Band, or Nation, and Notice of Incarceration of a Youth | Word | ||
| 09-541 | Notice to Federally Recognized Indian Tribe, Band or Nation | Word | ||
| 09-542 | Notice of Intervention and Request for Continuance - Indian Tribe | Word | ||
| 09-543 | Notice to Parent/Indian Custodian | Word | ||
| 09-545 | Notice to Bureau of Indian Affairs | Word | ||
| 09-547 | Motion and Order to Transfer Jurisdiction to Tribal Court | Word | ||
| 09-548 | Motion and Order for the Tribal Court to Accept Jurisdiction Under 25 U.S.C. 1911(b) | Word | ||
| 09-559 | Power of Attorney | Shana | ||
| 09-653 | Background Authorization | Word | ||
| PDF Translations: Amharic, Arabic, Cambodian, Chinese, French, Farsi, Korean, Laotian, Nepali, Oromo, Punjabi, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Spanish Word, Tagalog, Tigrigna, Vietnamese | ||||
| 09-670 | Discharge Report (Juvenile Rehabilitation Administration) | Word | ||
| 09-705 | Order of Continued Detention or Release (Juvenile Rehabilitation Administration) | Word | ||
| PDF Translations: Cambodian, Chinese, Laotian, Spanish, Vietnamese | ||||
| 09-706 | Parole Revocation Petition (Juvenile Rehabilitation Administration) | Word | ||
| PDF Translations: Cambodian, Chinese, Laotian, Spanish, Vietnamese | ||||
| 09-713 | Order Denying Parole Revocation Petition (Juvenile Rehabilitation Administration) | Shana | ||
| PDF Translations: Cambodian, Chinese, Laotian, Spanish, Vietnamese | ||||
| 09-714 | Order Revoking Parole (Juvenile Rehabilitation Administration) | Word | ||
| PDF Translations: Cambodian, Chinese, Laotian, Spanish, Vietnamese | ||||
| 09-746 | Notice of Sex/Kidnapping Offender Registration Requirements | Word | ||
| 09-746A | DSHS Sex/Kidnapping Offender Preregistration | Word | ||
| 09-747 | Notification of Release (Juvenile Rehabilitation Administration) | Word | ||
| 09-747A | Notification of Sex Offender Release (Juvenile Rehabilitation Administration) | Word | ||
| 09-758 | Notice to Child's Indian Tribe of alternative Residential placement (ARP) Proceeding | Shana | ||
| 09-759 | Motion, Declaration of Child's Return from Voluntary Foster Care Placement, and Order of Dismissal | Shana | ||
| 09-760 | Motion, Declaration of Child's Return from Voluntary Foster Care Placement, and Order of Dismissal | Shana | ||
| 09-761 | Indian Identity Request | Word | ||
| PDF Translations: French, Japanese, Russian, Spanish Word, Spanish, Vietnamese | ||||
| 09-762 | Petition for Court Validation of Voluntary Consent to Foster Care Placement of an Indian Child | Shana | ||
| 09-762A | Petition for Court Validation of Voluntary Consent to Foster Care Placement of An Indian Child (Indian Child with Disabilities) (Division of Developmental Disabilities | Word | ||
| 09-763 | Consent to Foster Care Placement and Court Certification for an Indian Child | Shana | 09-765 | Declaration of Adoption Facilitator - Indian Child | Word | 09-766 | Petition for Termination of Parent - Child Relationship (Indian Child) | Shana |
| 09-767 | Declaration of Notification - Voluntary Foster Care Placement Validation Hearing (Indian Child) | Shana | ||
| PDF Translations: Spanish | ||||
| 09-771 | Addendum to Petition - Indian Child | Shana | ||
| 09-777 | Indian Child: Compliance Checklist | Shana | ||
| 09-808 | JRA Notice and Finding of financial Responsibility | Shana | Word | |
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 09-809 | WorkFirst Work Experience (WEX) Referral | Word | ||
| 09-810 | WorkFirst Work Experience (WEX) Agreement | Word | ||
| 09-837 | Disclosure of Confidential HIV/AIDS Information | Shana | ||
| PDF Translations: Cambodian, Chinese, Laotian, Spanish, Vietnamese | ||||
| 09-860 | Interpreter Services Core Provider Agreement | Word | ||
| 09-876 | Permanency Planning Findings and Order (Child Wlith a Developmental Disability) | Word | ||
| 09-877 | Notice of Hearing Re: Out-of-Home Placement (Child with a Developmental Disability) | Word | ||
| PDF Translations: Spanish Word, Spanish, | ||||
| 09-878 | Order Approving Continued Out-of-Home Care (Child With a Developmental Disability) | Word | ||
| 09-892 | Petition for Review of Continued Out-of-Home Care (Child with Disabilities) (Division of Developmental Disabilities | Word | ||
| PDF Translations: Spanish Word, Spanish, | ||||
| 09-893 | Periodic Review of Individual Service Plan (DDD) | Word | ||
| PDF Translations: Spanish Word, Spanish, | ||||
| 09-891A | Important Notice to Parents using Child Care | |||
| PDF Translations: Arabic, Cambodian, Chinese, French, Hmong, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 09-894 | Contract Renewal of Acknowledgement of Requirements to Report Criminal Convictions (Juvenile Rehabilitation Administration) | Word | ||
| 09-895 | JRA Contractor Requirements for Responding to Situations of Sexual Misconduct (Juvenile Rehabilitation Administration) | Word | ||
| 09-961 | Declaration of Program Director (NATCEP) | Word | ||
| 09-966 | Authorization to Release Information to the Court (Children's Administration) | Word | ||
| 09-979 | Marital History | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 09-995 | Companion Home Contract Evaluation (DDD) | Word | ||
| 09-997 | Adoption Support Worksheet | Word | ||
| PDF Translations: Cambodian, Chinese, Laotian, Spanish Word, Spanish, Vietnamese | ||||
| 09-998 | Application For The Adoption Support Program and/or Reimbursement of Adoption Finalization Costs | Word | Shana | |
| PDF Translations: Cambodian, Chinese, Laotian, Spanish Shana, Spanish, Vietnamese | ||||
| 09-999 | Exhibit B Rate Sheet Licensed Staffed Residential Contract | Excel | ||
| 10-016 | Certification for License of Foster Home | Word | ||
| 10-017 | Termination of Foster Home License | Word | ||
| 10-043 | Family Home Study | Word | ||
| PDF Translations: Vietnamese | ||||
| 10-061 | Child's Registration | Shana | Word | |
| 10-083 | EPSDT Assessment | Word | ||
| 10-104A | Service Verification/Attendance Record (DDD) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Romanian, Russian, Somali, Spanish Word, Spanish, Tagalog, Vietnamese | ||||
| 10-114 | Adoption Data Card | Word | ||
| 10-161 | Mental Health Evaluation and Treatment Application for Certification | Shana | Word | |
| 10-165 | Application for License (Community Mental Health Services) | Word | ||
| 10-172 | Statement of Deficiencies and Plan of correction (Mental Health Division Licensing and Certification) | Word | ||
| 10-182 | Home Study File Checklist for Foster Care and/or Adoption | Word | ||
| 10-183 | Foster Home Inspection Checklist | Word | ||
| Translations: Spanish Shana, Spanish PDF | ||||
| 10-209 | Application for Program Certification (Children's Administration) | Shana | ||
| 10-210 | Staff Statement of Qualifications (Children's Administration) | Shana | ||
| 10-214 | Preauthorization for Services (Children's Administration) | Word | ||
| 10-217 | Nurse Delegation: Nursing Assistant Credentials and Training | Word | ||
| 10-231 | Adult Family Home (AFH) Placement Checklist (DDD) | Word | ||
| 10-232 | Provider Referral Letter For Supported Living/Group Home Providers | Word | ||
| 10-232A | Provider Referral Letter | Word | ||
| 10-234 | Individual with Challenging Support Issues (DDD) | Word | ||
| 10-237 | Notice of Transfer or Discharge (Residential Care) | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Shana, Spanish, Vietnamese | ||||
| 10-238 | Request for an Administrative Hearing (Residential Care Services) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Shana, Spanish, Vietnamese | ||||
| 10-241 | Report to Protective Services (Juvenile Rehabilitation Administration) | Word | ||
| 10-244 | Shared Parenting Plan (DDD) | Word | ||
| PDF Translations: Spanish Word, Spanish, | ||||
| 10-246 | Permanency Plan (Division of Developmental Disabilities | Word | ||
| PDF Translations: Spanish Word, Spanish, | ||||
| 10-247 | Placement Request (Division of Developmental Disabilities | Word | ||
| 10-248 | Compliance Agreement | Word | ||
| 10-248A | Compliance Agreement Continuation | Word | ||
| 10-254 | Public Health Nurse (PHN) Evaluation | Word | ||
| 10-255 | Public Health Nurse (PHN) Summary and Recommendations | Word | ||
| 10-257 | Foster Care Medical Unit (FCMU) DDD Placement (Division of Developmental Disabilities) | Word | ||
| PDF Translations: Russian, Spanish, Vietnamese | ||||
| 10-258 | Individual with Community Protection Issues (DDD) | Word | ||
| 10-261 | Foster Care Rate Assessment | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 10-264 | Independent Living Checklist | Word | ||
| PDF Translations: Cambodian, Chinese, Laotian, Spanish, Vietnamese | ||||
| 10-265 | Initial Independent Living Skills Plan | Word | ||
| PDF Translations: Cambodian, Chinese, Laotian, Spanish, Vietnamese | ||||
| 10-266 | Independent Living Progress Report | Word | ||
| PDF Translations: Cambodian, Chinese, Laotian, Spanish, Vietnamese | ||||
| 10-267 | Life Skills Inventory Independent Living Skills Assessment Tool | Word | ||
| PDF Translations: Cambodian, Chinese, Laotian, Spanish, Vietnamese | ||||
| 10-268 | Pre-Placement Agreement (Division of Developmental Disabilities | Word | ||
| 10-269 | Alternative Living Services Plan and Provider Report (DDD) (Division of Developmental Disabilities | Word | ||
| 10-270 | Adult Family Home/Boarding Home Admission Agreement(s) Attestation | Word | ||
| 10-271 | VPP File Checklist (Division of Developmental Disabilities | Word | ||
| 10-272 |
Cross-Systems Crisis Prevention and Intervention Plan (DDD) |
Word | ||
| 10-274 | Waiver Eligibility Determination Checklist (DDD) | Word | ||
| 10-276 | WTRS Consumer Response (Office of Deaf and Hard of Hearing) | Word | ||
| 10-277 | Request for Out-of-Home Care in the DDD Voluntary Placement Program | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 10-287 | Consumer Request for Special Needs Child Care Rate (Division of Child Care and Early Learning) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 10-288 | Provider Request for Additional Special Needs Payment (Division of Child Care and Early Learning) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 10-289 | Evaluation/Certification | Shana | ||
| 10-289A | Certification Review and Evaluation Report - Section A: Administration | Shana | ||
| 10-289B | Certification Review and Evaluation Report - Section B: Personnel | Shana | ||
| 10-289C | Certification Review and Evaluation Report - Section C: Physical Requirements | Shana | ||
| 10-289D | Certification Review and Evaluation Report - Section D: Instruction and Support | Shana | ||
| 10-289E | Certification Review and Evaluation Report - Section E: Financial | Shana | ||
| 10-289F | Certification Review and Evaluation Report - Section F: Evaluation Conclusion | Shana | ||
| 10-290 | Policy Agreement (Children's Administration) | Word | PDF Translations: Spanish Word, Spanish, | |
| 10-294 | Mandatory Report to Law Enforcement | Word | ||
| 10-295 | Companion Home Review and Evaluation | Word | ||
| 10-301 | Notification of Eligibility Review (Division of Developmental Disabilities) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 10-326 | Staffed Residential Rate Proposal | Excel | ||
| 10-327 | Residential Staff Schedule Reporting | Excel | ||
| 10-328 | Residential Site Approval Request (DDD) | Shana | ||
| 10-329 | Informed Consent for ICAP (Division of Developmental Disabilities) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 10-330 | Request For Legal Advice | Word | ||
| 10-331 | DDD Mortality Review Part 1. Provider Report | Word | ||
| 10-331B | DDD Mortality Review Part 2. Regional Quality Assurance Report | Word | ||
| 10-331C | DDD Mortality Review Part 3. Central Office Review | Word | ||
| 10-334 | Monitoring of Side Effects Scale (MOSES) (DDD) | Shana | ||
| 10-335 | Dyskinesia Identification System: DISCUS Rating (DDD) | Shana | ||
| 10-337 | Important Information for SSP Recipients and Their Payees (DDD) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 10-338a | Nursing Care Consultant (NCC) Home Visit Update (DDD) | Word | ||
| 10-339 | Nursing Care Consultant (NCC) Assessment (DDD) | Word | ||
| 10-340 | Pre-Inspection Preparation - Attachment A | Word | ||
| 10-341 | Records Request - Attachment B | Word | ||
| 10-342 | Resident and Staff List - Attachment C | Word | ||
| 10-343 | Environmental Tour - Attachment D | Word | ||
| 10-344 | Residential Interview and Record Review - Attachment E | Word | ||
| 10-345 | Administrative Records Review and Staff Interview - Attachment F | Word | ||
| 10-346 | Exit Preparation Worksheet - Attachment G | Word | ||
| 10-347 | Residential Care Services Notes - Attachment H | Word | ||
| 10-348 | Information Checklist (DDD) | Word | ||
| 10-349 | Allen/Marr Internal Oversight Review (DDD) | Word | ||
| 10-351 | Disclosure of Services (ADSA Boarding Homes) | Word | ||
| 10-353 | Documentation Request for Medical or Disability Condition | Word | ||
| PDF Translations: Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 10-354 | Application for Family Home Care for Children in Out of Home Placements | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 10-356 | Peer Counselor Application | Word | ||
| 10-357 | Peer Counselor Application (Grandfathered) | Word | ||
| 10-359 | Boarding Home Pre Inspection Preparation - Attachment A | Word | ||
| 10-360 | Boarding Home Request for Documentation - Attachment B | Word | ||
| 10-361 | Boarding Home Resident List - Attachment C | Word | ||
| 10-362 | Boarding Home Resident Characteristic Roster - Attachment D | Word | ||
| 10-363 | Boarding Home Resident Group Meeting - Attachment E | Word | ||
| 10-364 | Boarding Home Resident Sample Selection - Attachment F | Word | ||
| 10-365 | Boarding Home Resident Group Interview - Attachment G | Word | ||
| 10-366 | Boarding Home Collateral Interview - Attachment H | Word | ||
| 10-367 | Boarding Home Environmental and Food Service Observations - Attachment I | Word | ||
| 10-368 | Boarding Home Resident Record Review - Attachment J | Word | ||
| 10-369 | Boarding Home Staff Record - Attachment K | Word | ||
| 10-370 | Boarding Home Resident Care Service Notes - Attachment L | Word | ||
| 10-371 | Boarding Home Exit Preparation Worksheet - Attachment M | Word | ||
| 10-372 | Boarding Home Contract Requirements - Attachment N | Word | ||
| 10-373 | Boarding Home Environmental Observations - Contract Requirements - Attachment O | Word | ||
| 10-375 | Daily Attendance Record for Child Care Facilities | Word | ||
| PDF Translations: Spanish | ||||
| 10-376 | Password Change/Confirmation Request Nursing Home Facility Log-in | |||
| 10-377 | Notification of Age Four (4) Eligibility Expiration- | Word | ||
| PDF Translations: Arabic, Cambodian, Chinese, German, Korean, Laotian, Polish, Portuguese, Russian, Samoan, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 10-378 | Notification of Age Ten (10) Eligibility Expiration | Word | ||
| PDF Translations: Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 10-382 | Naturalization Services Pre-Screening | Shana | ||
| 10-388 | Referral For Initial Foster Home License | Word | ||
| 10-389 | Approved Sleeping Room List For Boarding Homes | Word | ||
| 10-389A | Additional Rooms List For Boarding Homes | Word | ||
| 10-393 | Cost Estimate Worksheet for Hearing Aids and Services | Word | ||
| 10-395 | Intensive Family Preservation Service (IFPS)/Family Preservation Service (FPS) Exit Summary | Word | ||
| 10-396 | SSI Letter (DDD) | Word | ||
| 10-400 | Information Request Letter | Word | ||
| PDF Translations: Amharic, Burmese, Cambodian, Chinese, Farsi German, Hindi, Korean, Laotian, Oromo, Polish, Punjabi, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Thai, Tigrigna, Ukrainian, Vietnamese | ||||
| 10-402 | Child Placing Agency Referral | Word | ||
| 10-403 | Abuse/Neglect Reporting Requirement Information | Word | ||
| 10-410 | Adult Family Home License Application | Word | ||
| 10-411 | Consumer Response: Do Not Hang Up Complaint | Word | ||
| 10-412 | Adult Family Home License Relinquishment Letter | Word | ||
| 10-413 | Application For Contract For Currently Licensed Boarding Home | Word | ||
| 10-416 | Foster Home Monitoring Visit | Word | ||
| 11-022 | Application for Vocational Rehabilitation Services | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Ukrainian, Vietnamese | ||||
| 11-045 | Work Experience (WEX) Referral (Food Stamp Employment and Training) | Word | ||
| 11-046 | Work Experience (WEX) Agreement (Food Stamp Employment and Training) | Word | ||
| 11-055 | Acknowledgement of My Responsibilities as the Employer of Individual Providers (DDD) | |||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish Word, Spanish, Vietnamese | ||||
| 11-058 | Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation) | Word | ||
| 11-066 | Assistive Listening Device(s) (ALD) Sign-Out Register (Office of Deaf and Hard of Hearing) | Word | ||
| 11-068 | DVR Internship Application (Division of Vocational Rehabilitation) | Word | ||
| 11-069 | DVR Internship Agreement (Division of Vocational Rehabilitation) | Word | ||
| 11-070 | DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation) | Word | ||
| 11-071 | DVR Employer Expense Worksheet (Division of Vocational Rehabilitation) | Word | ||
| 11-072 | DVR Internship Evaluation (Division of Vocational Rehabilitation) | Word | ||
| 11-078 | Centers for Independent Living (CILs), Title VII, Part B Two-Year Plan (Division of Vocational Rehabilitation) | Word | ||
| 11-079 | Centers for Independent Living (CILs), Title VII, Part B Annual Report (Division of Vocational Rehabilitation) | Word | ||
| 11-080 | Centers for Independent Living (CILs), Title VII, Part B Monthly Report (Division of Vocational Rehabilitation) | Word | ||
| 11-083 | Employees Approved to Provide IL Services and Type of Service Approved (Division of Vocational Rehabilitation) | Word | ||
| 12-006 |
Basis of Issuance Tables and Maximum Allowable Monthly Gross and
Net Income Standards for the Washington Basic Food Program PDF Instructions |
|||
| 12-123 | Statement of County Prosecutor's Expenditures (Food Stamp Program) | Word | ||
| 12-195 | Food Assistance Program Disqualification Consent Agreement | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 12-202 | Seasonal Child Care Master Packet | Shana | ||
| PDF Translations: Shana Spanish (with calculations), Spanish PDF | ||||
| 12-206 | Application for Disaster Food Stamp Assistance | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Tagalog, Somali, Spanish, Tagalog, Vietnamese | ||||
| 12-207 | Application for Disaster Cash Assistance | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 13-001 | Applicant Medical Report - Confidential | Word | ||
| 13-077 | Extension Request for Hospitalization (Medical Assistance Administration) | Shana | ||
| 13-021 | Physical Evaluation | Word | ||
| PDF Translations: Amharic, Tigrigna, Urdu | ||||
| 13-041 | Child's Medical and Family Background Report | Word | ||
| PDF Translations: Cambodian, Korean, Spanish, Vietnamese | ||||
| 13-364 | Sterilization Consent Form | Shana | ||
| PDF Translations: Spanish | ||||
| 13-364A | Client Statement Form (Sterilization) | Shana | ||
| PDF Translations: Spanish | ||||
| 13-365 | Hysterectomy Consent and Patient Information | Shana | ||
| 13-433 | Transfer/Discharge Health Summary (Juvenile Rehabilitation Administration) | Word | ||
| 13-566 | Application for Eligibility (Kidney Disease Program) | Shana | ||
| 13-585A | Incapacity Range of Joint Motion Chart | Shana | ||
| 13-645 | Adult Family Home Injuries and Accidents Log | Word | ||
| 13-658 | Infant Case Management (ICM) Intake | Word | ||
| 13-664G | Sign-up Form (Healthy Options) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 13-666 | Orthodontic Information | Word | ||
| 13-677 | Revia Authorization | Word | ||
| 13-678 Page 1 | Nurse Delegation: Consent for Delegation Process | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 13-678 Page 2 | Nurse Delegation: Instructions for Nursing Task | Word | Shana | |
| 13-678A | Nurse Delegation: PRN Medication | Word | Shana | |
| 13-678B | Nurse Delegation: Assumption of Delegation | Word | Shana | |
| 13-680 | Nurse Delegation: Rescinding Delegation | Word | Shana | |
| 13-681 | Nurse Delegation: Change in Medical Orders | Word | ||
| 13-683 | Well Child Exam - Infancy: 2-4 Weeks | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-683A | Well Child Exam - Infancy: 2 Months | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-683B | Well Child Exam - Infancy: 4 Months | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-683C | Well Child Exam - Infancy: 6 Months | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-683D | Well Child Exam - Infancy: 9 Months | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-683E | Well Child Exam - Infancy: 12 Months | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-684 | Well Child Exam - Early Childhood: 18 Months | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-684A | Well Child Exam - Early Childhood: 2 Years | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-684B | Well Child Exam - Early Childhood: 3 Years | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-684C | Well Child Exam - Early Childhood: 4 Years | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-685 | Well Child Exam - Late Childhood: 5 Years | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-685A | Well Child Exam - Late Childhood: 6 Years | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-685B | Well Child Exam - Late Childhood: 8 Years | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-685C | Well Child Exam - Late Childhood: 10 Years | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-685D | Well Child Exam - Late Childhood: 12 Years | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-686 | Well Child Exam - Adolescence: 14 Years | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-686A | Well Child Exam - Adolescence: 16 Years | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-686B | Well Child Exam - Adolescence: 18 Years | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-689 | Youth Suicide Risk Assessment (Juvenile Rehabilitation Administration) | Word | ||
| 13-690 | Medical Services Authorization (Juvenile Rehabilitation Administration) | Word | ||
| 13-691 | Application for the Medicare Savings Program | Shana | ||
| PDF Translations: Cambodian, Chinese, Ilocano, Korean, Laotian, Russian, Spanish, Tagalog, Vietnamese | ||||
| 13-692A | Boarding Home Dementia Screening Tool | Shana | ||
| 13-695 | Ask About Medical | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-696 | Insurance Information Request | Shana | Word | |
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Punjabi, Russian, Serbo-Croatian, Spanish, Vietnamese | ||||
| 13-705 | Health Insurance Premium Payment Program Application | Word | ||
| 13-708 | Voucher for Interim Pharmacy and Medical Services for Foster Children | Word | ||
| 13-709 | Referral/Authorization (Medicaid Treatment Child Care Program) | Word | ||
| 13-710 | Statement of Medical Necessity (MTCC) (Children's Administration) | Word | ||
| 13-711 | Treatment Questionnaire | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 13-712 | Medicaid Personal Care Client RSN Transmittal | Shana | ||
| 13-713 | Fast Track Service Agreement | Shana | ||
| 13-714 | Pharmacy Statement (525-106) | Word | ||
| 13-715 | Adjustment Request (525-109) | Shana | Word | |
| 13-720 | Suboxone Authorization | Word | ||
| 13-721 | Justification for Use of Miscellaneous Parenteral Supply Procedure Code (B9999) | Shana | ||
| PDF Translations: Spanish | ||||
| 13-726 | Negative Pressure Wound Therapy | Shana | ||
| 13-727 | Medical Necessity For Wheelchair Purchase (For Home Clients Only) | Word | ||
| 13-728 | Low Air-Loss Therapy Systems | Shana | ||
| 13-729 | Medical Necessity For Wheelchair Purchase For Nursing Facility (NF) Clients | Shana | Word | |
| 13-730 | Hospital Injury Report | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 13-732 | Authorization to Release Information (Medical Assistance Administration) | Shana | ||
| 13-733 | Request for Proviso Funding Request (Division of Developmental Disabilities) | Word | ||
| 13-734 | Documentation of First Use of Medicaid Benefits (DDD) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 13-736 | Washington Medicaid Integration Partnership (WMIP) Exemption Disenrollment Request | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 13-737 | Washington Medicaid Integration Partnership (WMIP) AI/AN Exemption/Disenrollment Request | Shana | ||
| 13-738 | Shared Responsibility Information | Word | ||
| 13-739 | Vision Care Limitation Extension | Word | ||
| 13-740 | Medicaid Integration Partnership (WMIP) Sign-up | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 13-741 | Corrected Claim - Standard Cover Sheet | Shana | ||
| 13-742 | Supporting Documentation - Standard Cover Sheet | Shana | ||
| 13-743 | Oral Enteral Nutrition Worksheet | Word | ||
| 13-745 | Justification for Use of B9998 Miscellaneous Enteral Nutrition Procedure Code and Limitation Extension Request | Word | ||
| 13-746 | DSHS/Medicaid Hospice Notification | Word | ||
| 13-747 | Hospital Bed Evaluation | Word | ||
| 13-748 | Washington Medicaid Integration Partnership (WMIP) Primary Care Provider (PCP) | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 13-749 | Campral Authorization (Division of Alcohol and Substance Abuse) | Word | ||
| 13-750 | Suboxone Exemption Request (Division of Alcohol and Substance Abuse) | Word | ||
| 13-752 | Pediatric Palliative Care (PPC) Referral & 5-Day Notification | Shana | Word | |
| 13-753 | Request to Change Reimbursement | Shana | ||
| 13-754 | GAU Sign Up Form for Picking Your Health Care | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 13-755 | Airway Optical Ordering Form | Shana | ||
| 13-756 | Fax/Written Request Basic Information | Word | ||
| 13-757 | Pet Scan Information | Word | ||
| 13-760 | Medical Necessity For Authorization of Catheters | Word | Shana | |
| 13-761 | Oral Enteral Nutrition Worksheet Expedited Prior Authorization Request | Word | ||
| 13-770 | Request For Additional MG's of Synagis Due to Client Weight Increase or Child Turning One Year Old During RSV Season | Word | Shana | |
| 13-771 | Request For Synagis (Not Managed Care/Healthy Options) | Word | ||
| 13-772 | Hearing Aid Limitation Extension Request | word | ||
| 13-776 | Nursing Services Referral | Word | ||
| 13-778 | Managed Care Exemption/Disenrollment Request | Word | ||
| 13-781 | Application For Washington State Take Charge Family Planning Services | Word | ||
| 13-784 | Nursing Services Assessment | Word | ||
| 13-785 | Bariatric Surgery Request | Word | ||
| 13-786 | Physical, Occupational, and Speech Therapy Limitation Extension Request | Word | ||
| 13-787 | Out of State Medical Services Request | Word | ||
| 13-788 | Denture/Partial Appliance Request For Skilled Nursing Facility Client | Word | ||
| 13-789 | Citizenship Documentation and Identity Declaration | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 13-791 | Vivitrol IM Physician Prior Authorization | Word | ||
| 13-792 | Welcome to Infant Case Management (Also called ICM) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 13-793 | Pharmacy Prescription Volume Report | Word | ||
| 13-794 | Health & Recovery Services Administration (HRSA) Prescription Form | Word | ||
| 13-798 | Prescription Drug Authorization Fax Request (HRSA) | Word | ||
| 13-809 | Denture or Partial Denture Agreement of Acceptance | Word | ||
| 13-821 | Initial Certification Authorization for Admission | Word | ||
| 13-822 | Extension Certification Authorization for Continue | Word | ||
| 13-823 | SSN Referral / Take Charge | Word | ||
| 13-830 | ICF/MR Admissions Review Team Checklist | Word | ||
| 13-831 | Durable Medical Equipment | Word | ||
| 13-832 | Tysabri (Natalizumab) J2323 Request | Word | ||
| 13-835 | General Information for Authorization | Word | ||
| 13-835A | Pharmacy Information Authorization | Word | ||
| 13-836 | Family and Children's Medical Benefits Renewal | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 13-838 | Acute Medicine and Rehab Admit/Update | Word | ||
| 13-839 | Acute Physical Medicine and Rehabilitation (PM&R) Update | Word | ||
| 13-840 | Patient Review and Coordination Referral Form | Word | ||
| 13-841 | Application For Chest Wall Oscillator | Word | ||
| 13-842 | Statement of Medical Necessity | Word | ||
| 13-843 | Foster Care Initial Health Evaluation | Word | ||
| 13-847 | HRSA Home Health & Hospice (including PPC) Authorization Request | Word | ||
| 13-849 | Removable Prosthetic Prior Authorization | Word | ||
| 13-850 | Insomnia Referral Worksheet | Word | ||
| 13-851 | Psychiatric Referral Summary | Word | ||
| 13-851A | Psychoactive Medication Treatment Plan | Word | ||
| 13-852 | Xolair (Omalizumab) | Word | ||
| 13-851C | Psychoactive Medication Treatment Plan Annual Continuation of Medication | Word | ||
| 13-858 | Antipsychotic Medications | Word | ||
| 13-863 | Tooth Chart | Word | ||
| 13-864 | HRSA Exception to Rule Request | Word | ||
| 13-865 | Psychological/Psychiatric Evaluation | Word | ||
| 13-866 | HRSA Limitation Extension Request | Word | ||
| 13-870 | HRSA Limitation Extension Request: Incontinent Supplies | Word | ||
| 13-871 | HRSA Limitation Exception to Rule Request: Compression Garments | Word | ||
| 13-872 | HRSA Limitation Exception to Rule Request: Bathroom Equipment | Word | ||
| 13-873 | MSS Post Pregnancy Eligibility Tool | Word | ||
| 13-874 | MSS Prenatal Eligibility Tool | Word | ||
| 14-001 | Application for Benefits | Word | ||
| PDF Translations: Amharic, Arabic, Cambodian, Chinese, Hindi, Japanese, Korean, Laotian, Russian, Somali, Spanish, Tagalog, Tigrigna, Ukrainian, Vietnamese | ||||
| 14-012 | Consent | Word | ||
| PDF Translations: Albanian, Amharic, Arabic, Burmese, Cambodian, Chinese, Farsi, Finnish, French, German, Hindi, Hmong, Hungarian, Indonesian, Japanese, Korean, Kurdish, Laotian, Marathi, Mongolian, Nepali, Oromo, Polish</ |