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
10-672 Meaningful Day Eligibility Checklist (Home and Community Services)
27-147A In-Home Environmental Adaptations General Utility and Repair Property Release Agreement (Aging and Long-Term Support Administration)
02-740 Private Duty Nursing (PDN) Time Log for the Month of (Home and Community Services)
27-240 Medicaid Provider Disclosure Statement for Nursing Facility
02-615 Social Services Invoice / Receipt Packet Cover (Home and Community Services)
13-943 Certified Community Residential Supports and Services (CCRSS) Infection Prevention and Control (IPC) Complaint Investigation Pathway
13-939 Residential Care Services (Adult Family Home, Assisted Living Facility, Enhanced Services Facility) Community Programs Infection Prevention and Control (ICP) InspectionTool
27-234 CCLS Small Business Self-Certification Statement
27-232 Central Contracts and Legal Services (CCLS) Department of Enterprise Services (DES) Late Filing Justification
27-231 Central Contracts and Legal Services (CCLS) Source Contract Justification