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(asc) Form Name File Format
18-398 Client Overpayment Notice
18-334 How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs
18-235 Initial payment (Interim Assistance Reimbursement Authorization)
18-176A Address Release Information Letter
18-176 Address Release Information Letter
18-097 Statement of Resources and Expenses
18-078 Application for Nonassistance Support Enforcement Services
17-345 Transitional Care Management Exchange of Information (Developmental Disability Administration)
17-337 Personal Service Request / Standard Referral (Developmental Disabilities Administration)
17-337 Personal Service Request / Standard Referral (Behavioral Health Administration)
17-333 Assisted Living Facility / Enhanced Services Facility / Adult Family Home Request for Records (Residential Care Services)
17-305 DPI Authorization for Release of Information (Division of Program Integrity)
17-301 Medical Expense Examples (Community Services Division, Economic Services Administration)
17-300 BHA Personal Information Release (Behavioral Health Administration)
17-299 Vendor Agreement Information (Behavioral Health Administration)
17-297 Removal and Transport Directive (Behavioral Health 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)
17-284 Preferred Sign Language Interpreter List (Office of Deaf and Hard of Hearing)
17-270 Authorization for Use or Disclosure of Psychotherapy Notes
17-266 Contractor Designated Contact(s) Background Check (Division of Vocational Rehabilitation)
17-265A WA Cares Fund Request for Approval to Subcontract Checklist
17-265 DSHS Request for Approval to Subcontract Checklist
17-264 DVR Background Check Reporting (Division of Vocational Rehabilitation)
17-263 Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation)