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(asc) Form Name File Format
18-433 Declaration of Support Payments (Division of Child Support)
18-399A Non-SSPS Client / Provider Overpayment AFRS Coding Computation
18-399 Social Service Incorrect Payment Computation
18-398B Department of Children, Youth, and Families (DCYF) Client Overpayment Notice
18-398A Vendor / Provider Overpayment Notice
18-398 Client Overpayment Notice
18-334 How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs
18-235 Initial payment (Interim Assistance Reimbursement Authorization)
18-176A Address Release Information Letter
18-176 Address Release Information Letter
18-097 Statement of Resources and Expenses
18-078 Application for Nonassistance Support Enforcement Services
17-337 Personal Service Request / Standard Referral (Developmental Disabilities Administration)
17-337 Personal Service Request / Standard Referral (Behavioral Health Administration)
17-321 Pre-Admission Screening and Resident Review (PASRR) Equipment Purchase Request
17-301 Medical Expense Examples (Community Services Division, Economic Services Administration)
17-300 BHA Personal Information Release (Behavioral Health Administration)
17-299 Vendor Agreement Information (Behavioral Health Administration)
17-297 Removal and Transport Directive (Behavioral Health Administration)
17-296 Residential Quality Assurance Certification Evaluation Checklist for Alternative Living Providers (Developmental Disabilities Administration)
17-295 Residential Quality Assurance Certification Evaluation Checklist for Companion Homes Providers (Developmental Disabilities Administration)
17-294 Outpatient Competency Restoration Program Clinical Screening (Behavioral Health Administration)
17-292 Assistive Communication Technology (ACT) Program Service Request / Work Order for Induction Loops (Office of the Deaf and Hard of Hearing)
17-284 Preferred Sign Language Interpreter List (Office of Deaf and Hard of Hearing)
17-266 Contractor Designated Contact(s) Background Check (Division of Vocational Rehabilitation)