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.
| Number(asc) | Form Name | File Format | |
|---|---|---|---|
| 27-248 | Residential Habilitation for Dependent Youth Acknowledgement (Developmental Disabilities Administration) | ||
| 27-247 | Residential Habilitation for Dependent Agreement for Youth (Age 18-20) (Developmental Disabilities Administration) | ||
| 27-245 | Central Contracts and Legal Services (CCLS) Vendor Agreement Review | ||
| 27-240 | Medicaid Provider Disclosure Statement for Nursing Facility | ||
| 27-234 | CCLS Small Business Self-Certification Statement | ||
| 27-233 | CCLS General Terms and Conditions (GTC) Change Request | ||
| 27-232 | CCLS DES Late Filing Justification | ||
| 27-231 | CCLS Source Contract Justification | ||
| 27-230 | CCLS Emergency Contract Justification | ||
| 27-229 | CCLS Sole Source Amendment Justification | ||
| 27-228 | CCLS Additional Delegated Authority Request | ||
| 27-226 | Adult Family Home Management Agreement: Attestation Information and Attachments (Residential Care Services) | ||
| 27-223 | Adult Family Home Policies and Procedures Attestation | ||
| 27-222 | Consent to Release and/or Use Confidential Information for Completing an Adult Home License Application | ||
| 27-221 | DSHS Claim of Stolen EBT Benefits |
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| 27-220 | Disposition of Remains / Release of Body Permit (Developmental Disabilities Administration) | ||
| 27-219 | Death Notification Checklist for Medical Providers (Developmental Disabilities Administration) | ||
| 27-218 | Death Notification Checklist for Residential Habilitation Center (RHC) Staff (Developmental Disabilities Administration) | ||
| 27-215 | Teleservice Agreement (Developmental Disabilities Administration) | ||
| 27-210 | DDA Authorization for Release of Referral Video (Developmental Disabilities Administration) | ||
| 27-209 | Nursing Home Informal Dispute Resolution Request (Residential Care Services) | ||
| 27-208 | Declaration to Adult Protective Services | ||
| 27-207 | Acknowledgement Statement (Meaningful Day) (Home and Community Services) | ||
| 27-189 | Asset Verification Authorization (Home and Community Services) | ||
| 27-188 | Initial Opiate Prescription Informed Consent (Behavioral Health Administration) |
