Electronic DSHS Forms

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.

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).

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.

Choose search option and begin typing the form #
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Number(desc) Form Name File Format
01-110 Protective Payee Report
01-110A Protective Payee Periodic Social Services Report
01-110C Protective Payee Report Continuation
01-205 Basic Food Workfare Activity Report
01-210 Transmittal of Client Funds from the Protective Payee
01-212 ALTSA Nurse Delegation Referral and Communication Case / Resource Manager's Request
02-516 Adult Family Home Resident Personal Belongings Inventory (Residential Care Services)
02-528 Fair Hearing Withdrawal
02-556 Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration)
02-573 Background check Identification Verification (Office of Deaf and Hard of Hearing)
02-586 Temporary Employment Hours Tracking Log
02-589 Companion Home Outside Employment Notification and Review (Developmental Disabilities Administration)
02-592 Application for Approval of Interpreter Continuing Education Activity
02-611 Statement of Understanding: Mid-Certification Review
02-632 Residential Provider's Report of Weapon Ownership in Residential Setting
02-634 Additional Information Needed for ILP TANF
02-690 Student Evaluation Summary Report
02-691 Student Class Evaluation
02-692 Community Instructor Class List Tracking Log
03-076 Employee Personal Property Damage/Loss Claim
03-077 Release of All Claims
03-133 Safety Incident / Close Call Report
03-374B Agreement on Nondisclosure of Confidential Information - Non-Employee
03-374D ESA Non-Dislcosure of Confidential Information Agreement - Non Employee
03-374E Confidential Information, Fraud and Abuse
03-387 DSHS Notice of Privacy Practices for Client Medical Information
03-387A DSHS Notice of Privacy Practices for Client Medical Information without Acknowledgement
03-389A Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790)
03-391 Report of Possible Client Assault
03-490 Employee / Contractor Awareness IRS Safeguard Training Certification
03-494 Medication Administration Competency Assessment Tool
04-220A Indian Heritage Questionnaire (Developmental Disabilities Administration)
04-442 Nursing Home Credit Balance Report
04-446 Tell Us How We are Doing! (Division of Child Support)
04-449 Participants Feedback (Domestic Violence Intervention Treatment)
04-449A Survivors Feedback (Domestic Violence Intervention Treatment)
05-010 Rule Exception Request
05-013 Request for Hearing
05-246 Notice of Action Exception to Rule (Excluding AFH)
05-249 Adult Residential Care Services Notice of a Change
05-251 Rule Change Comments (Residential Care Services)
05-252 Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation)
05-254 Federal Subminimum Wage Certificate Holder
05-255 Medicaid Transformation Demonstration Notice of Action Exception to Rule
05-256 Notice of Action Exception to Rule for AFH Daily Rates
05-258 Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment
05-259 Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment)
05-260 Change of Address for an Existing DVIT Certification (Domestic Violence Intervention Treatment)
05-261 Add, Change, or Remove Direct Service Staff for a Certified DVIT Program (Domestic Violence Intervention Treatment)
05-262 Add or Remove a Service for an Existing DVIT Certification (Domestic Violence Intervention Treatment)
06-123 Nursing Assistant Training and Testing Reimbursement
06-124 Cost of Care Adjustment Request (Developmental Disabilities)
06-125 Residential Allowance Request / Insufficient Income and Housemate Allowance (Developmental Disabilities Administration)
06-125A Residential Allowance Request / Start Up Costs (Developmental Disabilities Administration)
06-125B Residential Allowance Request / Damage and Major Expenses (Developmental Disabilities Administration)
06-159 Psychologist and Sex Offender Treatment Provider Invoice
06-162 Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral
06-165 Extended Foster Care Denial Letter (Children's Administration)
06-168 AFH Change in Licensed Bed Capacity - Increase (Adult Family Home) (Residential Care Services)
06-169 AFH Change in Licensed Bed Capacity - Decrease (Adult Family Home) (Residential Care Services)
06-171 Funding and Expenditure Data (Tribal)
06-172 Domestic Violence Prevention Account
06-173 Medical Evidence Reimbursement
06-174 Enhanced Rate Proposal
06-175 Individual Provider (IP) Travel Time Request
06-176 ALF Change in Licensed Resident Bed Capacity or Use of Rooms
06-177 Residential Training Roster / Reimbursement (Developmental Disabilities Administration)
06-180 Nursing Services Activity Report for Home and Community Services (HCS)
06-181 Nursing Services Activity Report for AAAs
06-182 Public Records Customer Experience Survey
07-042B Self-Employment Income Report
07-081 Participation Reimbursement
07-097 Individual Provider Planned Action Notice Training / Certification (Home and Community Services)
07-098 Self Employment Monthly Sales and Expense Worksheet
07-103 Participant Reimbursement
07-103A Participant Reimbursement with Interpreter Declaration
07-104 Financial Communication to Social Services
07-107 Exception to Rule and Notice Guardianship Fees and Related Costs (Aging and Long-Term Support Administration and Developmental Disabilities Administration)
09-004C Voluntary Placement Agreement for Child or Youth with Developmental Disabilities
09-013 Vendor Affidavit of Lost, Stolen, or Destroyed Warrant
09-052 Affidavit of Forged Endorsement
09-280B Petition for Modification - Administrative Order
09-415 Authorization for Expenditure (Non-Employee)
09-508 Waiver of Statute of Limitations
09-520 Request for Conference Board
09-653 Background Check Authorization
09-693 Declaration of Lawful Custody
09-728 Washington State Addendum to Box 2 of Part B - Plan Administrator Response
09-741 Child Support Order Review Request
09-762A Petition for Court Validation of Voluntary Consent to Foster Care Placement of An Indian Child (Indian Child with Disabilities) (Developmental Disabilities Administration)
09-809 WorkFirst Word Experience (WEX) Referral
09-810 WorkFirst Word Experience (WEX) Agreement
09-876 Permanency Planning Findings and Order (Child With a Developmental Disability)
09-877 Notice of Hearing Re: Out-of-Home Placement (Child with a Developmental Disability)
09-878 Order Approving Continued Out-of-Home Care (Child With a Developmental Disability)
09-892 Petition for Review of Continued Out-of-Home Care (Child with Disabilities) (Developmental Disabilities Administration)
09-893 Periodic Review of Individual Service Plan (DDA)
09-989 Confidentiality Statement - Tribal Employee
09-995 Companion Home Evaluation and Review (Developmental Disabilities Administration)
10-104B Service Verification / Attendance Record For Alternative Living Providers (Developmental Disabilities Administration)
10-210 Staff Statement of Qualifications
10-217 Nurse Delegation: Nursing Assistant Credentials and Training
10-231 Adult Family Home (AFH) Placement Checklist (DDA)
10-232 Provider Referral Letter For Residential Services (Developmental Disabilities Administration)
10-232A AFH / ARC Provider Referral Letter
10-234 Individual with Challenging Support Issues (DDA)
10-234A Individual with Complex Behaviors (Aging and Long-Term Support Administration)
10-237 Nursing Home Transfer or Discharge Notice (Residential Care Services)
10-238 Request for an Administrative Hearing (Residential Care Services)
10-244 Shared Parenting Plan (Developmental Disabilities)
10-246 Permanency Plan
10-255 Public Health Nurse (PHN) Summary and Recommendations
10-258 Individual with Community Protection Issues (DDA)
10-268 Pre-Placement Agreement (Developmental Disabilities Administration)
10-269 Alternative Living Services Plan and Provider Progress Report (Developmental Disabilities Administration)
10-269A Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration)
10-270 Assisted Living Facility Admission Agreement(s) Attestation
10-272 Cross-System Crisis Plan (DDA)
10-276 WTRS Consumer Response (Office of Deaf and Hard of Hearing)
10-277 Request for Children's Residential Services
10-301 Notification of Eligibility Review (Developmental Disabilities Administration)
10-326 Staffed Residential Rate Proposal (Developmental Disabilities Administration)
10-328 Residential Site Approval Request
10-329 Informed Consent for ICAP
10-330 Request For Legal Advice
10-331 DDA Mortality Review Provider Report (Developmental Disabilities Administration)
10-334 Monitoring of Side Effects Scale (MOSES) (DDA)
10-337 Important Information for SSP Recipients and Their Payees (DDA)
10-339 Nursing Care Consultant (NCC) Assessment (DDA)
10-348 Community Protection Program Information Checklist and Risk Assessment Consent (Developmental Disabilities Administration)
10-349 Comprehensive Regional Review Tool
10-351 Disclosure of Services Required by RCW 18.20.300
10-353 Documentation Request for Medical or Disability Condition
10-359 Assisted Living Facility Pre Inspection Preparation - Attachment A
10-360 Boarding Home Request for Documentation - Assisted Living Facility Request For Documentation - Attachment B
10-361 Assisted Living Facility Resident List - Attachment C
10-362 Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D
10-363 Assisted Living Facility Resident Group Meeting - Attachment E
10-365 Assisted Living Facility Resident Interview - Attachment G
10-366 Assisted Living Facility Other Contact Interview - Attachment H
10-367 Assisted Living Facility Environmental Observations - Attachment I
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-372 Assisted Living Facility Contract Requirements - Attachment N
10-373 Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O
10-377 Notification of Age Four (4) Eligibility Expiration-
10-378 Notification of Age Ten (10) Eligibility Expiration
10-382 Naturalization Services Pre-Screening
10-389 Room List For Assisted Living Facilities (ALF)
10-389A Additional Room List For Assisted Living Facilities (ALF)
10-393 Cost Estimate Worksheet for Hearing Aids and Services
10-396 SSI Letter (DDA)
10-400 Information Request Letter
10-403 Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
10-410 Adult Family Home License Application
10-411 Consumer Response: Do Not Hang Up Complaint
10-412 Adult Family Home License Relinquishment Letter
10-413 Application For Contract For Currently Licensed Boarding Home
10-417 Adult Family Home Caregiver Experience Attestation (CEA)
10-422 Adult Family Home (AFH) Quality Improvement Initial Visit
10-423 Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services
10-424 Voluntary Participation Statement (Developmental Disability Administration)
10-427 School District Communication
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
10-438 Long-Term Care Partnership (LTCP) Asset Designation
10-442 Goal Setting and Action Planning Worksheet
10-448 Nurse Delegation Contract Monitoring Chart Audit
10-467 ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services)
10-468 HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
10-471 Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration)
10-472 Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration)
10-481 Health Action Plan (HAP)
10-486 Assisted Living Facility Food Service Observations - Attachment P
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-488 Extended Foster Care Program Consent
10-489 Confidential Health Information Consent Agreement
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
10-503 Limitation Extension Evaluation
10-504 Limitation Extension Request for Clients Under Age 21
10-505 Limitation Extension Task Explanation
10-506 Limitation Extension Request Checklist
10-508 Adult Family Home Disclosure of Services Required by RCW 70.128.280
10-509 Pediatric Symptoms Checklist (PSC-17)
10-535 Enhanced Services Facility Application
10-570 Intake and Referral
10-571 Overnight Planned Respite Services Individualized Agreement
10-572 Respite Application for Overnight Planned Respite (OPRS), Emergent and/or Planned Short-Term Stay Services at an RHC
10-573 Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination
10-574 Roads to Community Living (RCL) Person Centered Transition Planning
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-580 Adult Day Services Referral
10-582 Notification of Age 19 Eligibility Review (Developmental Disabilities Administration)
10-583 DDA PASRR Cover Sheet
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
10-585 Adult Family Home Information Changes
10-589 Comprehensive Functional Assessment of Recreation
10-590 Comprehensive Functional Assessment of Physical Therapy
10-591 Assisted Living Facility License Application
10-592 Comprehensive Functional Assessment of Direct Care Independent Living Skills
10-593 Restraint / Support Evaluation
10-593A Restraint / Support Evaluation Continuation
10-594 Comprehensive Functional Assessment of Communication
10-595 Comprehensive Functional Assessment of Occupational Therapy
10-596 Comprehensive Functional Assessment of Adult Training Programs
10-601 Assisted Living Facility Information Changes
10-602 Enhanced Services Facility Information Changes
10-603 Nursing Home Information Changes
10-604 Supported Living Information Changes (Residential Care Services)
10-605 ICF / IID Information Changes (Residential Care Services)
10-611 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services)
10-612 Certified Community Residential Services and Supports (CCRSS) Pre-Certification Evaluation Preparation (Residential Care Services)
10-613 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Observation(Residential Care Services)
10-614 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services)
10-615 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Family / Representative / Collateral Contact Interview (Residential Care Services)
10-616 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Interview (Residential Care Services)
10-617 Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services)
10-618 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services)
10-619 Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (Residential Care Services)
10-620 Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services)
10-621 Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services)
10-622 Certified Community Residential Services and Supports (CCRSS) Group Training Home Food Service Observations and Interviews (Residential Care Services)
10-623 DDA PASRR Significant Change Invalidation (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review)
10-625 State Task Checklist (Aging and Long-Term Support Administration)
10-626 Staffing Pattern (Aging and Long-Term Support Administration)
10-627 Liability Insurance Review (Aging and Long-Term Support Administration)
10-628 Trust Fund Review (Aging and Long-Term Support Administration)
10-629 Pet Record Review (Aging and Long-Term Support Administration)
10-630 Paid Feeding Assistant Program Review (Aging and Long-Term Support Administration)
10-631 Staff Qualification and Background Review (Aging and Long-Term Support Administration)
10-632 TB Testing Review for Staff (Aging and Long-Term Support Administration)
10-633 TB Testing Review for Resident (Aging and Long-Term Support Administration)
10-634 Medication Assistant Endorsement (Aging and Long-Term Support Administration)
10-635 Residential Transition Exchange of Information (Developmental Disabilities Administration)
10-636 Meaningful Day Monthly Calendar
10-637 Meaningful Activity Plan (MAP) Discovery
10-638 AFH Meaningful Day - Monthly Activities and Challenging Behavior Log
10-639 Overnight Planned Respite Services (OPRS) Certification Evaluation (Developmental Disabilities Administration)
10-640 Emphasis on Hands-On Skills Practice: Planning Attestation (Home and Community Services)
10-641 Community Instructor Qualification Tool (Home and Community Services)
10-642 Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services)
11-019 Vocational Information (Division of Vocational Rehabilitation)
11-022 Application for Vocational Rehabilitation Services
11-030 Service Delivery Outcome Report (Community Rehabilitation Program - CRP)
11-034B Basic Food Eligibility Requirements: What You Need to Know
11-045 Work Experience (WEX) Referral (Food Stamp Employment and Training)
11-046 Work Experience (WEX) Agreement (Food Stamp Employment and Training)
11-055 Acknowledgement of My Responsibilities As The Employer of My Individual Providers
11-058 Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation)
11-066 Assistive Communication Technology Request (Office of Deaf and Hard of Hearing)
11-067 Monthly Budget Worksheet (Division of Vocational Rehabilitation)
11-068 DVR Internship Application (Division of Vocational Rehabilitation)
11-069 DVR Internship Agreement (Division of Vocational Rehabilitation)
11-070 DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation)
11-071 DVR Employer Expense Worksheet (Division of Vocational Rehabilitation)
11-072 DVR Internship Evaluation (Division of Vocational Rehabilitation)
11-078 Centers for Independent Living (CILs), Title VII, Part B Two-Year Plan (Division of Vocational Rehabilitation)
11-079 Centers for Independent Living (CILs) Title VII, Part B, Contract Annual Report
11-080 Centers for Independent Living (CILs) Title VII, Part B Monthly Report
11-084 Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation)
11-088 DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet
11-093 Outreach Attendance (Office of the Deaf and Hard of Hearing)
11-097 Service Delivery Outcome Report (Independent Living Services - IL)
11-098 Vocational Assessment Worksheet
11-100 Community Rehabilitation Program (CRP) Generic Update Report
11-106 Pre-ETS (Pre-Employment Transition Services) Self-Advocacy Training (Division of Vocational Rehabilitation)
11-107 Pre-ETS (Pre-Employment Transition Services) Peer Mentoring (Division of Vocational Rehabilitation)
11-110 Pre-ETS (Pre-Employment Transition Services) Informational Interview (Division of Vocational Rehabilitation)
11-111 Pre-ETS (Pre-Employment Transition Services) Job Exploration (Division of Vocational Rehabilitation)
11-112 Pre-ETS (Pre-Employment Transition Services) Job Shadow (Division of Vocational Rehabilitation)
11-113 Pre-ETS (Pre-Employment Transition Services) Social Skills (Division of Vocational Rehabilitation)
11-114 Referral Contact Sheet
11-115 Workplace Readiness Report
11-116 Work-Based Learning Report
11-117 Student Summary Report
11-118 Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation)
11-119 Informational Interview Worksheet (Division of Vocational Rehabilitation)
11-121 Enhanced Case Management Referral Consideration (Developmental Disabilities Administration)
11-123 Service Delivery Outcome Plan: WBL - Experience A
11-124 Service Delivery Outcome Plan: WBL - Experience B
11-125 Service Delivery Outcome Plan: WBL - Experience C
11-132 90 Day Review (Division of Vocational Rehabilitation)
11-133 Jobs and Training Inventory (Division of Vocational Rehabilitation)
11-134 Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation)
11-142 Service Delivery Outcome Plan: Pre-ETS IL Skills Training
11-146 Supported Employment Referral (Economic Services Administration)
11-149 Division of Vocational Rehabilitation (DVR) Customer Job Seeker Accommodation Worksheet
12-006 Basis of Issuance Tables and Maximum Allowable Monthly Gross and Net Income Standards for the Washington Basic Food Program
12-195 Disqualification Consent Agreement
12-206 Application for Disaster Food Benefits
12-207 Application for Disaster Cash Assistance
12-209 Client Fraud Report
12-210 Medicaid Provider Fraud Report
13-021 Physical Evaluation
13-585A Range of Joint Motion Evaluation Chart
13-645 Adult Family Home Injuries and Accidents Log
13-678 Page 1 Nurse Delegation: Consent for Delegation Process
13-678 Page 2 Nurse Delegation: Instructions for Nursing Task
13-678A Nurse Delegation: PRN Medication
13-678B Nurse Delegation: Assumption of Delegation
13-680 Nurse Delegation: Rescinding Delegation
13-681 Nurse Delegation: Change in Medical Orders
13-692A Assisted Living Facility (ALF) Dementia Screening Tool
13-712 Behavioral Health Personal Care Request for BHO / MCO Funding (Aging and Long-Term Support Administration)
13-713 Fast Track Service Agreement
13-734 Documentation of First Use of Medicaid Benefits (DDA)
13-738 DDA / CA Request to Cost Share
13-776 HCS / AAA Nursing Services Referral (Home and Community Services)
13-780 Nursing Services Basic Skin Assessment (Home and Community Services)
13-783 Pressure Injury Assessment and Documentation (Home and Community Services)
13-784 Nursing Services Assessment
13-830 Admissions Review Team Checklist for Admission to an ICF / IID or SONF at a Residential Habilitation Center (RHC) (Developmental Disabilities Administration)
13-851 Psychiatric Referral Summary
13-851A Psychoactive Medication Treatment Plan
13-851C Psychoactive Medication Treatment Plan Annual Continuation of Medication
13-865 Psychological / Psychiatric Evaluation
13-893 Nurse Delegation: Request For Additional Units
13-899 Review of Medical Evidence
13-903 DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration)
13-905 Autistic Disorder Confirmation (Developmental Disabilities Administration)
13-906 Therapy Assessment Bed Rails or Side Rails (Home and Community Services)
13-911 DDA Nursing Service Referral (Developmental Disabilities Administration)
13-915 Information for Respite Care Service Providers: Addendum to TCARE Assessment
13-917 CCSS Medical / Dental Services Authorization (Community Crisis Stabilization Services) (Developmental Disabilities Administration)
14-001 Application for Cash or Food Assistance
14-012 Consent
14-050 Statement of Health, Education, and Employment
14-057 Child Support Referral
14-057B Noncustodial Parent Child Support Enforcement Application
14-057D Child Support Referral Continuation
14-068 Financial Statement (Division of Vocational Rehabilitation)
14-076 Change of Circumstances
14-078 Eligibility Review
14-084 Social Service Referral
14-105 Interview Appointment for Applicant (Community Services Division)
14-113 Your Cash and Food Assistance Rights and Responsibilities
14-144A Medical Disability Decision
14-151 Request for DDA Eligibility Determination
14-155 Senior Citizens Service Application
14-162 Veteran's Referral
14-222 Statement of Collateral Information
14-222 SUMMARY Statement of Collateral Information Summary
14-223 Statement from School
14-224 Statement from Landlord/Manager
14-225 Acknowledgement of Services
14-238 Client Income Report
14-252 Employment Verification
14-264 Application for Telecommunications Equipment
14-299 Adult Assessment Referral (Economic Services Administration)
14-300 Level One Pre-Admission Screening and Resident Review (PASRR)
14-310 Client Status Change Report
14-332 Disability Assessment
14-341 Application to Convert Payment Services Only (PSO) Case to Full Collection Services
14-349 Protective Payee Assessment
14-381 WorkFirst Individual Responsibility Plan
14-401 Notification of Address Disclosure Request - Part 1
14-401A Notification of Address Disclosure Request - Part 2
14-402 Notice to Parents (WorkFirst)
14-416 Eligibility Review for Long Term Services and Supports
14-426 Protective Payee Payment Plan, Case Assignment, and Closure Notice
14-427 Teen Parent Living Assessment
14-431 Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration)
14-431A Community Crisis Stabilization Services (CCSS) Medical / Dental Services Authorization (Developmental Disabilities Administration)
14-432 Direct Deposit Enrollment
14-436 Statement of Adult Acting in Loco Parentis (As a Parent)
14-438 Stop Work
14-439 WASHCAP Application
14-440 Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing)
14-443 Financial / Social Services Communication
14-449 Unmet Need Breakdown
14-453 Protective Payee Decision
14-454 Estate Recovery: Repaying the State for Medical and Long Term Services and Supports
14-459 Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration)
14-460 Notice of Insufficient Information (Developmental Disabilities Administration)
14-462 Epilepsy Verification Request (Developmental Disabilities Administration)
14-463 Waiver Transportation Record (DDA)
14-467 Mid-Certification Review
14-473 Inventory for Client and Agency Planning (ICAP) Letter
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
14-478 Treatment Verification Request
14-484 Nurse Delegation: Nursing Visit
14-489 SSIF Introduction Letter
14-491 NSA Representative Checklist forDDA Review
14-492 Assessment Meeting Wrap-up
14-493 Requirement to Identify a Representative (Developmental Disabilities Administration)
14-495 Naturalization Letter
14-501 Community Resource Declaration
14-502 SSI Hearing Denial
14-503 Interim Assistance Reimbursement Agreement Cover
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center
14-515 Notice and Finding of Responsibility
14-517 DSHS Letter Requesting Non Work SSN
14-520 Your DSHS Cash or Food Assistance Benefits
14-521 Your Rights (Home and Community Services)
14-525 Incapacity Review for Medical Care Services
14-526 Chemical Dependency Treatment Verification Request
14-527 Substance Use Disorder Requirements (HEN Referral Program)
14-528 Chemical Dependency NonCooperation
14-529 Substance Use Disorder Requirements (ABD / PWA)
14-530 Disability Review
14-532 Authorized Representative
14-534 SDCP Eligibility Checklist (Home and Community Services)
14-535 Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration)
14-538 Pre-Admission Screening and Resident Review (PASRR) Addendum
14-541 ABAWD Requirement: Medical Report (Able Bodied Adults without Dependents)
14-542 Application for New Program Certification (Domestic Violence Intervention Treatment)
14-543 Application for Renewal Program Certification (Domestic Violence Intervention Treatment)
14-544 Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment)
14-547 Continuing Care Retirement Community (CCRC) Registration Application
15-031 Nursing Facility Notice of Action
15-184 Volunteer Chore Service Referral
15-186 DSHS Volunteer Application
15-215 AFH Quality Improvement Visit Assessment
15-252 DRW Access Request Checklist
15-274 Assistance Available Schedule (DDA)
15-282A Request for Enrollment in Developmental Disabilities Administration (DDA) Home and Community Based Services (HCBS) Waiver or Request to Change from One DDA HCBS Waiver to Another
15-290 Notification of Annual Assessment Review and Person Centered Services Planning Meeting
15-291 Person Centered Service Planning and Annual Assessment Meeting
15-295 Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration)
15-304 HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration)
15-314 Client Necessary Supplemental Accommodation Representative Requirement Checklist
15-318 DDA Crisis Diversion Bed Referral and Intake Information
15-331 Annual Assessment Checklist (Developmental Disability Administration)
15-342 Notice of Exception to Rule Decision
15-344 Private Duty Nursing Logs and Skilled Nursing Tasks Log
15-356 DDA Community Protection Program Chaperone Agreement
15-358 Client Referral Summary (Developmental Disabilities Administration)
15-360 Residential Services Capacity Profile
15-365 Community Protection Treatment Worksheet Quarterly Review
15-366 Change of Address
15-376 Skin Observation Protocols
15-379 Staff Add-on Request for Client Specific Need (Developmental Disabilities Administration))
15-380 Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration)
15-381 Respite Assessment Worksheet
15-382 Positive Behavior Support Plan (PBSP)
15-383 Functional Behavioral Assessment (FA)
15-384 Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA)
15-385 Provider Consent For Use of Restrictive Procedures Requiring an ETP
15-387 Children’s Respite Application
15-388 Alternative Living Review and Evaluation
15-389 Certified Community Residential Services and Support Initial Application
15-398 Medically Intensive Children's Program (MICP) Application
15-419 Refusal of Services Statement
15-420 Request For ICF / IID or SONF Admission
15-422 No Paid Services Group
15-424 Staffed Residential Cost of Care Adjustment Request
15-435 Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration
15-436 Request for Adult Family Home Application Fee Waiver
15-447 Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services)
15-449 Adult Family Home Disclosure of Charges Required by RCW 70.128.280
15-456 RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
15-458 Adult Family Home Notice of Transfer or Change
15-473 Notification of Age 18 Eligibility Expiration
15-474 Notification of Age 20 Eligibility Expiration
15-492 Medicaid Transformation Demonstration Service Notice
15-493 PASRR Client Referral
15-494 Guardian / Family Response to Individual Habilitation Plan (IHP) Notification (Developmental Disabilities Administration)
15-495 Individual Habilitation Plan (IHP) (Developmental Disabilities Administration)
15-496 Individual Habilitation Plan (IHP) Revision (Developmental Disabilities Administration)
15-508 Consent and Service Agreement (Developmental Disabilities Administration)
15-509 Provider Progress Report of Community Guide and Engagement Services (Developmental Disabilities Administration))
15-512 Companion Home and Alternative Living Services Incident Report (Developmental Disabilities Administration)
15-514 Companion Home (CH) Client Individual Financial Plan (IFP) (Developmental Disabilities Administration)
15-515 CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration)
15-516 Companion Home Quarterly Report (Developmental Disabilities Administration)
15-517 Application for Transition from Group Home to Group Training Home
15-548 Adult Family Home Administrator Training Instructor Application (Home and Community Services)
15-549 Community Instructor Application: DSHS Adult Education (Home and Community Services)
15-550 Community Instructor Application (Home and Community Services)
15-551 Community Instructor Training Program Application and Updates (Home and Community Services)
15-552 Curriculum Approval Application (Home and Community Services)
15-553 Long-Term Care Worker Basic Training Enhancement Instructions and Application (Home and Community Services)
15-554 Facility Instructor Application (Home and Community Services)
15-555 Facility Training Program Application and Updates (Home and Community Services)
15-556 Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration)
15-558 Adult Family Home (AFH) Resident Significant Change Assessment Request
15-559 Adult Family Home Referral Request (Developmental Disabilities Administration)
15-560 Room Requirements Checklist (Home and Community Services)
16-072 NonAssistance Support Enforcement Information (Division of Child Support)
16-107 Noncustodial Parent's Rights and Responsibilities
16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration
16-182 Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration)
16-191 SOLA Vehicle Trip Log (Developmental Disabilities Administration)
16-193 Nurse Aide Registry Inquiry (ADSA)
16-194 DDA Specialty Training Sign-Up Sheet
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative
16-197 Assisted Living Facility Policies and Procedures Attestation
16-198 Individual Provider Notification: Stop Work Notice
16-199 New Case/Resource Manager Technology Training Checklist
16-200 Memo to Provider for Behavior Support, Counseling, and Consultation Services
16-202 5-Day Investigation Report
16-202A Plan of Correction (5-Day Investigation)
16-203 SIS-A Rating Key (Developmental Disabilities Administration)
16-205 Personal Emergency Plan Information
16-213 Verification of Legal Status
16-218 Intake Cover Letter to Tribes
16-230 Children's Residential Services
16-234 Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF)
16-234A Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC))
16-235 Photo Release
16-237 DDA GovDelivery Communication Request (Developmental Disabilities Administration)
16-237A ALTSA GovDelivery Communication Request (Aging and Long-Term Support Administration)
16-242 Ask DSHS
16-243 Community Services Office (CSO) Compliments and Concerns (Economic Services Administration)
17-011 Forms and Publications Request
17-041 Request for Records
17-063 Authorization
17-116 AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion
17-123 Spoken Language Interpreter Service Appointment Record
17-123A Request for Sign Language Interpreter
17-155 Sign Language Interpreter Registration
17-180 Personal Information Release (Economic Services Administration)
17-194 Request for Mental Health Service Information
17-208A PRISM Access Request for Multiple Organizations
17-211 Authorization for SSI Facilitation Records (Economic Services Administration)
17-226 AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration)
17-227 DSHS / HCA Systems Access Request
17-229 Pre-Admission Screening and Resident Review (PASRR) Records Request
17-230 Non-Emergency Medical Transportation (NEMT) for PASRR Program Request
17-231 Mental Incapacity Evaluation (MIE) Contractor Travel Plan
17-238 ODHH Approved Sign Language Interpreter Complaints
17-242 Residential Habilitation Center (RHC) Informed Consent (Developmental Disabilities Administration)
17-253 DSHS Background Check System (BCS) Access Request
17-257 Companion Home Client Budget Worksheet (Developmental Disabilities Administration)
17-258 Companion Home Client Cash Ledger (Developmental Disabilities Administration)
17-259 Companion Home Client Inventory Record
17-260 Companion Home Gift Card or Pre-paid Credit Card Ledger (Developmental Disabilities Administration)
17-261 Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing)
17-262 Companion Home Physical and Safety Requirements Review (Developmental Disabilities Administration)
17-263 Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation)
17-264 DVR Background Check Reporting (Division of Vocational Rehabilitation)
17-265 DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation)
17-266 Contractor Designated Contact(s) Background Check (Division of Vocational Rehabilitation)
18-078 Application for Nonassistance Support Enforcement Services
18-097 Statement of Resources and Expenses
18-176 Address Release Information Letter
18-176A Address Release Information Letter
18-235 Initial payment (Interim Assistance Reimbursement Authorization)
18-334 How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs
18-398 Client Overpayment Notice
18-398A Vendor Overpayment Notice
18-399 Social Service Incorrect Payment Computation
18-399A Non-SSPS Client / Provider Overpayment AFRS Coding Computation
18-433 Declaration of Support Payments (Division of Child Support)
18-463 New Hire Reporting Methods and Instructions
18-464 Introduction to New Hire Reporting
18-483 Employer Payment Identification Instructions
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information
18-544 Transmittal of Resident Personal Funds
18-551 School Statement
18-555 Financial Information Sheet
18-607 Child Care Verification
18-627 SSP Client Overpayment Notice (State Supplementary Program)
18-681 Request for Collection of Uninsured Health Care Expenses
18-682 Detail Sheet – Uninsured Health Care Expenses
18-700 Direct Deposit Authorization
18-701 Request for Income Information for Purposes of Entering or Enforcing a Child Support Order
19-074 Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation)
20-273 Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program
20-330 Incident Report to DDA (Developmental Disabilities Administration)
21-059 Children's Staffed Residential Quality Assurance Assessment
21-060 Children’s State Operated Living Alternative (SOLA) Quality Assurance Assessment
21-061 Companion Home Monthly Emergency Evacuation Practice and Water Temperature Record (Developmental Disabilities Administration)
23-034 Alternative Living Financial Report
23-045 Community Services Division (CSD) Financial Confidence Wheel (Economic Services Division)
27-043 Contractor Intake
27-044A Contractor Information Update (for existing DSHS contractors)
27-051 DSHS / Union Contract Decision Process
27-053 Paternity Information
27-057 Voluntary Placement Services Provider Referral Letter (DDA)
27-059 Fingerprint Appointment
27-063 Voluntary Placement Services For Youth (Age 18-21)
27-076 Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
27-081 Employment and Day Program Services Providers: Mandatory Reporting of Abuse, Improper Use of Restraint, Neglect, Personal or Financial Exploitation, Abandonment of a Child or Vulnerable Adult (Developmental Disability Administration)
27-089 Fingerprint-Based Background Check Notice
27-094 Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration)
27-096 Permission to Share Documents for Reimbursement of Health Care Expenses
27-109 BCCU Applicant Affidavit
27-110 Applicant Request for a Copy of Background Check Information
27-115 Privacy Complaint
27-122 HCS / AAA / DDA Individual Provider Contractor Intake
27-123 Provider Owned Housing Memorandum of Understanding Renter Attestation
27-124 Provider Owned Housing Memorandum of Understanding Residential Provider Attestation
27-130 Authorization for Alternate EBT Cardholder
27-143 CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool
27-144 CSD Disability Eligibility Review Contractor Self-Assessment Monitoring Tool
27-147 Housing Modification Property Release Agreement
27-155 Declaration on Commercial Purposes
27-156 Notice and Consent of Communication via Text
27-168 Authorization of Disclosure (Economic Services Administration)
27-175 DVR Additional Contractor Information (Division of Vocational Rehabilitation)
27-176 Release of Liability (Developmental Disabilities Administration)
27-177 Notice and Consent of Communication via Text
27-178 Adult Protective Services (APS) Administrative Hearing Request