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.

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.

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Number Form Name(desc) File Format
02-766 Care Agreement for Beneficiaries and their Caregivers (WA Cares)
05-272 Case Manager Instructions Following a Hearing Decision
02-760 Case Mix Index Detail (CMID) Report Authorization (Home and Community Living Administration (HCLA))
27-228 CCLS Additional Delegated Authority Request
27-234 CCLS Small Business Self-Certification Statement
27-229 CCLS Sole Source Amendment Justification
10-700 CCRSS Follow-Up Visit (Certified Community Residential Services and Supports, Residential Care Services.)
13-942 CCRSS Infection Prevention and Control (IPC) Complaint Investigation Tool (Residential Care Services)
15-515 CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration)
27-232 Central Contracts and Legal Services (CCLS) Department of Enterprise Services (DES) Late Filing Justification
27-230 Central Contracts and Legal Services (CCLS) Emergency Contract Justification
27-231 Central Contracts and Legal Services (CCLS) Source Contract Justification
27-245 Central Contracts and Legal Services (CCLS) Vendor Agreement Review
15-606 Certification Evaluation Checklist Children’s Residential Habilitation Providers
15-608 Certification Evaluation Checklist Enhanced Respite Services for Children (Home and Community Living Administration)
17-296 Certification Evaluation Checklist for Alternative Living Providers (Developmental Disabilities Administration)
17-295 Certification Evaluation Checklist for Companion Homes Providers (Home and Community Living Administration)
10-666 Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Home and Community Living Administration)
15-605 Certification Evaluation Checklist Intensive Habilitation Services for Children Providers (Home and Community Living Administration (HCLA)
10-645 Certification Evaluation Client Interview (Developmental Disabilities Administration)
10-646 Certification Evaluation Legal Representative Interview (Developmental Disabilities Administration)
10-647 Certification Evaluation Staff Interview (Developmental Disabilities Administration)
10-720 Certified Children’s Residential Services Initial Application (Developmental Disabilities Administration)
15-389 Certified Community Residential Services and Support (CCRSS) Initial Application
10-698 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Administrator Record Review and Interview (Residential Care Services)