Nurse Delegation Forms

Find mandatory nurse delegation forms required for Registered Nurse Delegators who contract with DSHS. Including all official delegation, consent, instruction, billing, and medical‑order‑change forms so providers can meet state requirements and complete delegation tasks correctly.

Forms used by all contracted Registered Nurse Delegators according to DSHS Contract - Nurse Delegation Services 1008XS.

 

Nurse Delegation Mandatory Forms

  • Nurse Delegation: Referral Form  (DSHS 01-212 Word)
  • Nurse Delegation: Billing Form (Not mandatory but encouraged) (DSHS 06-200  Excel | PDF)
  • Nurse Delegation: Credentials and Training Verification (DSHS 10-217 Word | PDF)
  • Nurse Delegation: Consent for Delegation Process (DSHS 13-678 Page 1 Word | PDF | Additional Languages)
  • Nurse Delegation: Instructions for Nursing Task (DSHS 13-678 Page 2 Word | PDF)
  • Nurse Delegation: PRN Medication (DSHS 13-678A Word | PDF)
  • Nurse Delegation: Assumption of Delegation (DSHS 13-678B Word | PDF)
  • Nurse Delegation: Rescinding Delegation (DSHS 13-680 Word | PDF Format)
  • Nurse Delegation: Change in Medical Orders (DSHS 13-681 Word | PDF)
  • Nurse Delegation: Request For Additional Unit (DSHS 13-893 Word | PFD)
  • Nurse Delegation: Nursing Visit (DSHS 14-484 Word | PDF)