Electronic DSHS Forms

The Electronic DSHS Forms page is a centralized repository where the public can find and download official forms for Washington Department of Social and Health Services programs.

You 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.

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.

Number Form Name Form File
05-255 Medicaid Transformation Project Notice of Action Exception to Rule
12-210 Medicaid Provider Fraud Referral
27-240 Medicaid Provider Disclosure Statement for Nursing Facility
27-094 Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration)
10-636 Meaningful Day Monthly Calendar
10-672 Meaningful Day Eligibility Checklist (Home and Community Services)
10-637 Meaningful Activity Plan (MAP) Discovery
27-076 Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
10-438 Long-Term Care Partnership (LTCP) Asset Designation
20-338 Limited Power of Attorney for WA Cares Fund Benefits