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(asc) File Format
14-495 Naturalization Letter
02-531 Native Language Identifier
10-661 Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration)
11-067 Monthly Budget Worksheet (Division of Vocational Rehabilitation)
10-334 Monitoring of Side Effects Scale (MOSES) (DDA)
14-467 Mid-Certification Review
17-231 Mental Incapacity Evaluation (MIE) Contractor Travel Plan
10-634 Medication Assistant Endorsement (Aging and Long-Term Support Administration)
13-953 Medication Administration Record (MAR) (Developmental Disabilities Administration)
15-398 Medically Intensive Children's Program (MICP) Application
17-301 Medical Expense Examples (Community Services Division, Economic Services Administration)
06-173 Medical Evidence Reimbursement
14-144A Medical Disability Decision
14-431 Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration)
15-492 Medicaid Transformation Project Service Notice
05-255 Medicaid Transformation Project Notice of Action Exception to Rule
12-210 Medicaid Provider Fraud Report
27-240 Medicaid Provider Disclosure Statement for Nursing Facility
27-094 Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration)
10-636 Meaningful Day Monthly Calendar
10-672 Meaningful Day Eligibility Checklist (Home and Community Services)
10-637 Meaningful Activity Plan (MAP) Discovery
27-076 Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
10-438 Long-Term Care Partnership (LTCP) Asset Designation
19-074 Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation)