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(desc) Form Name File Format
27-043 New Contractor Intake
27-044A Contractor Information Update (for existing DSHS contractors)
27-053 Paternity Information
27-059 Fingerprint Appointment
27-063 Out-of-Home Services Agreement for Youth (Age 18-21) (Developmental Disabilities Administration)
27-076 Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
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
27-123 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
27-147 Housing Modification Property Release Agreement
27-147A In-Home Environmental Adaptations General Utility and Repair Property Release Agreement (Aging and Long-Term Support Administration)
27-155 Declaration on Commercial Purposes
27-156 Notice and Consent of Communication via Text or Unencrypted Email
27-175 DVR Additional Contractor Information (Division of Vocational Rehabilitation)
27-176 Release of Liability (Developmental Disabilities Administration)
27-178 Adult Protective Services (APS) Administrative Hearing Request
27-179 Adult Family Home (AFH) Informal Dispute Resolution (IDR) Request (Residential Care Services)
27-182 DSHS Request for Positive Identification – Thumbprint