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.

Choose search option and begin typing the form #
Keyword Search
Number Form Name(desc) File Format
05-258 Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment
14-300 Level One Pre-Admission Screening and Resident Review (PASRR)
10-627 Liability Insurance Review (Aging and Long-Term Support Administration)
10-658 Life Skills 90-Day (Quarterly) Report (Developmental Disabilities Administration)
10-503 Limitation Extension Evaluation
10-506 Limitation Extension Request Checklist
10-504 Limitation Extension Request for Clients Under Age 21
10-505 Limitation Extension Task Explanation
20-338 Limited Power of Attorney for WA Cares Fund Benefits
10-438 Long-Term Care Partnership (LTCP) Asset Designation
27-076 Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
10-637 Meaningful Activity Plan (MAP) Discovery
10-672 Meaningful Day Eligibility Checklist (Home and Community Services)
10-636 Meaningful Day Monthly Calendar
27-094 Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration)
27-240 Medicaid Provider Disclosure Statement for Nursing Facility
12-210 Medicaid Provider Fraud Referral
05-255 Medicaid Transformation Project Notice of Action Exception to Rule
15-492 Medicaid Transformation Project Service Notice
14-431 Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration)
14-144A Medical Disability Decision
06-173 Medical Evidence Reimbursement
17-301 Medical Expense Examples (Community Services Division, Economic Services Administration)
15-398 Medically Intensive Children's Program (MICP) Application
13-953 Medication Administration Record (MAR) (Developmental Disabilities Administration)