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
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information
14-532 Authorized Representative
27-269 Authorization to Release Information (Office of Refugee and Immigrant Assistance)
17-270 Authorization for Use or Disclosure of Psychotherapy Notes
17-211 Authorization for SSI Facilitation Records (Economic Services Administration)
09-415 Authorization for Expenditure (Non-Employee)
27-130 Authorization for Alternate EBT Cardholder
17-063 Authorization
11-066 Assistive Communication Technology Request (Office of Deaf and Hard of Hearing)
17-261 Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing)
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K
10-717 Assisted Living Facility Staff Interview - Attachment F (Home and Community Living Administration)
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-361 Assisted Living Facility Resident List - Attachment C
10-365 Assisted Living Facility Resident Interview - Attachment G
10-363 Assisted Living Facility Resident Group Meeting - Attachment E
10-362A Assisted Living Facility Resident Characteristic Roster and Sample Selection Addendum - Attachment D
10-362 Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D
10-360 Assisted Living Facility Request for Documentation - Attachment B
10-576 Assisted Living Facility Pre-Inspection Preparation (Residential Care Services)
10-359 Assisted Living Facility Pre Inspection Preparation - Attachment A
16-197 Assisted Living Facility Policies and Procedures Attestation
10-366 Assisted Living Facility Other Contact Interview - Attachment H
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-689 Assisted Living Facility Monitoring Visit (Residential Care Services)