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(desc) | Form Name | File Format | |
|---|---|---|---|
| 00-398 | Phase 1 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services) | ||
| 00-399 | Phase 2 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services) | ||
| 00-410 | Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control Assessment (IPC) Pathway (Residential Care Services) | ||
| 00-412 | RCS (AFH, ALF, and ESF) Infection Prevention and Control (IPC) Assessment Tool for COVID-19 (Residential Care Services) (Adult Family Home, Assisted Living Facility, and Enhanced Services Facility) | ||
| 00-412A | RCS (AFH, ALF, and ESF) Infection Prevention and Control (IPC) Assessment Notes for COVID-19 (Residential Care Services) (Adult Family Home, Assisted Living Facility, and Enhanced Services Facility) | ||
| 00-413 | Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Tool for COVID-19 (Residential Care Services) | ||
| 00-413A | Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Notes for COVID-19 (Residential Care Services) | ||
| 01-110 | Protective Payee Report | ||
| 01-110A | Protective Payee Periodic Social Services Report | ||
| 01-110C | Protective Payee Report Continuation | ||
| 01-205 | Able Bodied Adults Without Dependents (ABAWD) Activity Report | ||
| 01-210 | Transmittal of Client Funds from the Protective Payee | ||
| 01-218 | Community Inclusion Rate Adjustment for Staffed Residential Rate | ||
| 02-516 | Adult Family Home Resident Personal Belongings Inventory (Residential Care Services) | ||
| 02-556 | Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration) | ||
| 02-566 | Protected Health Information (PHI) Amendment | ||
| 02-573 | Background check Identification Verification (Office of Deaf and Hard of Hearing) | ||
| 02-586 | Temporary Employment Hours Tracking Log | ||
| 02-592 | Application for Approval of Interpreter and Translator Continuing Education Activity | ||
| 02-611 | Statement of Understanding: Mid-Certification Review |
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| 02-632 | Residential Provider's Report of Weapon Ownership in Residential Setting | ||
| 02-634 | Additional Information Needed for ILP TANF | ||
| 02-690 | Student Evaluation Summary Report | ||
| 02-692 | Community Instructor Class List Tracking Log | ||
| 02-709 | Adult Family Home (AFH) Personnel Changes (Aging and Long-Term Support Administration) | ||
| 02-716 | Rapid Response Team 2 Request (Residential Care Services) (Aging and Long-Term Support Administration) | ||
| 03-076 | Employee Personal Property Damage/Loss Claim | ||
| 03-077 | Release of All Claims | ||
| 03-133 | Safety Incident / Close Call Report | ||
| 03-374B | Agreement on Nondisclosure of Confidential Information - Non-Employee | ||
| 03-374D | ESA Non-Dislcosure of Confidential Information Agreement - Non Employee | ||
| 03-374E | Nondisclosure of Confidential Information Agreement for Non-Employee (eJAS Access) | ||
| 03-387 | DSHS Notice of Privacy Practices for Client Medical Information |
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| 03-387A | DSHS Notice of Privacy Practices for Client Medical Information without Acknowledgement |
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| 03-387B | DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs | ||
| 03-389A | Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790) | ||
| 03-391 | Report of Possible Client Assault | ||
| 03-490 | Employee / Contractor Awareness IRS Safeguard Training Certification | ||
| 04-449A | Survivors Feedback (Domestic Violence Intervention Treatment) | ||
| 05-013 | Request for Hearing |
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| 05-246 | Notice of Action Exception to Rule (Excluding AFH) | ||
| 05-248 | On-Site Review (Office of Refugee and Immigrant Assistance) | ||
| 05-249 | Adult Residential Care Services Notice of a Change | ||
| 05-252 | Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation) | ||
| 05-255 | Medicaid Transformation Demonstration Notice of Action Exception to Rule | ||
| 05-256 | Notice of Action Exception to Rule for AFH Daily Rates | ||
| 05-258 | Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment | ||
| 05-259 | Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment) | ||
| 05-260 | Change of Address for an Existing DVIT Certification (Domestic Violence Intervention Treatment) | ||
| 05-261 | Add, Change, or Remove Direct Service Staff for a Certified DVIT Program (Domestic Violence Intervention Treatment) | ||
| 05-262 | Add or Remove a Service for an Existing DVIT Certification (Domestic Violence Intervention Treatment) | ||
| 05-267 | Self-Assessment and Monitoring Tool (Home and Community Services) | ||
| 05-268 | Community Instructor Self-Assessment (Home and Community Services) | ||
| 05-269 | Community Instructor Self-Assessment for Contract Renewal and/or for Newly Established Contracts (Home and Community Services) | ||
| 06-124 | Cost of Care Adjustment (COCA) (Developmental Disabilities) | ||
| 06-162 | Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral | ||
| 06-176 | Assisted Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms | ||
| 06-180 | Nursing Services Activity Report for Home and Community Services (HCS) | ||
| 06-181 | Nursing Services Activity Report for AAAs | ||
| 06-182 | Public Records Customer Experience Survey | ||
| 06-184 | Adult Family Home (AFH) Capacity Increase Working Papers (Residential Care Services) | ||
| 06-186 | Financial Solvency Information (Aging and Long-Term Support Administration) | ||
| 06-188 | Adult Protective Services (APS) Investigations Fact Sheet (Aging and Long-Term Support Administration) |
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| 06-189 | Notice of Suspension of Supported Living Services (Developmental Disabilities Administration) | ||
| 06-199 | Specialized Evaluation and Consultation Quarterly Report (Developmental Disabilities Administration) n | ||
| 07-042B | Self-Employment Income Report |
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| 07-098 | Self Employment Monthly Sales and Expense Worksheet |
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| 07-107 | Exception to Rule and Notice Guardianship Fees and Related Costs (Aging and Long-Term Support Administration and Developmental Disabilities Administration) | ||
| 09-004C | Voluntary Placement Agreement for Child or Youth with Developmental Disabilities | ||
| 09-013 | Vendor Affidavit of Lost, Stolen, or Destroyed Warrant | ||
| 09-052 | Affidavit of Forged Endorsement | ||
| 09-280B | Petition for Modification - Administrative Order |
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| 09-415 | Authorization for Expenditure (Non-Employee) | ||
| 09-508 | Waiver of Statute of Limitations |
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| 09-520 | Request for Conference Board |
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| 09-653 | Background Check Authorization | ||
| 09-693 | Declaration of Lawful Custody |
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| 09-728 | Washington State Addendum to Box 2 of Part B - Plan Administrator Response | ||
| 09-741 | Child Support Order Review Request |
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| 09-989 | Confidentiality Statement - Tribal Employee | ||
| 10-104B | Service Verification / Attendance Record For Alternative Living Providers (Developmental Disabilities Administration) | ||
| 10-210 | Staff Statement of Qualifications | ||
| 10-232 | Provider Referral Letter For Residential Services (Developmental Disabilities Administration) | ||
| 10-234 | Individual with Challenging Support Issues (DDA) | ||
| 10-234A | Individual with Complex Behaviors (Aging and Long-Term Support Administration) | ||
| 10-237 | Nursing Home Transfer or Discharge Notice (Residential Care Services) | ||
| 10-238 | Request for an Administrative Hearing (Residential Care Services) | ||
| 10-269 | Alternative Living Services Plan and Provider Progress Report (Developmental Disabilities Administration) | ||
| 10-269A | Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration) | ||
| 10-277 | Request for Children's Out-of-Home Services (Developmental Disabilities Administration) | ||
| 10-301 | Notification of Eligibility Review (Developmental Disabilities Administration) |
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| 10-329 | Informed Consent for ICAP | ||
| 10-330 | Request For Legal Advice | ||
| 10-331 | DDA Mortality Review Provider Report (Developmental Disabilities Administration) | ||
| 10-334 | Monitoring of Side Effects Scale (MOSES) (DDA) | ||
| 10-337 | Important Information for SSP Recipients and Their Payees (DDA) | ||
| 10-348 | Community Protection Program Information Checklist and Risk Assessment Consent (Developmental Disabilities Administration) | ||
| 10-351 | Disclosure of Services Required by RCW 18.20.300 | ||
| 10-353 | Documentation Request for Medical Condition and Residual Functional Capacity | ||
| 10-360 | Boarding Home Request for Documentation - Assisted Living Facility Request For Documentation - Attachment B | ||
| 10-366 | Assisted Living Facility Other Contact Interview - Attachment H | ||
| 10-368 | Assisted Living Facility Resident Record Review - Attachment J | ||
| 10-369 | Assisted Living Facility Staff Sample / Record Review - Attachment K | ||
| 10-370 | Assisted Living Facility Notes / Worksheet - Attachment L | ||
| 10-371 | Assisted Living Facility Exit Preparation Worksheet - Attachment M | ||
| 10-373 | Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O | ||
| 10-377 | Notification of Age Four (4) Eligibility Expiration- |
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| 10-378 | Notification of Age Ten (10) Eligibility Expiration |
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| 10-389 | Room List For Assisted Living Facilities (ALF) | ||
| 10-389A | Additional Room List For Assisted Living Facilities (ALF) | ||
| 10-393 | Cost Estimate Worksheet for Hearing Aids and Services | ||
| 10-400 | Information Request Letter |
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| 10-403 | Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult | ||
| 10-413 | Application For Contract For Currently Licensed Assisted Living Facility | ||
| 10-415 | Contract Monitoring Checklist On-Site Review (Office of Refugee and Immigrant Assistance) | ||
| 10-423 | Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services | ||
| 10-424 | Voluntary Participation Statement (Developmental Disability Administration) |
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| 10-437 | Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility | ||
| 10-442 | Goal Setting and Action Planning Worksheet | ||
| 10-448 | Nurse Delegation (ND) Contract Monitoring Chart Audit (Home and Community Services, Aging and Long Term Support Administration) | ||
| 10-468 | HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
| 10-472 | Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration) | ||
| 10-486 | Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration) | ||
| 10-487 | Assisted Living Facility Medication Pass Worksheet - Attachment Q | ||
| 10-489 | Confidential Health Information Consent Agreement |
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| 10-501 | Referral to DSHS for Basic Food Employment and Training (BFET) | ||
| 10-504 | Limitation Extension Request for Clients Under Age 21 | ||
| 10-508 | Adult Family Home Disclosure of Services Required by RCW 70.128.280 | ||
| 10-574 | Roads to Community Living (RCL) Person Centered Transition Planning | ||
| 10-577 | Assisted Living Facility Other Contact Information - Attachment R | ||
| 10-584 | Data Summary Report and Recommendations (Developmental Disabilities Administration) | ||
| 10-585 | Adult Family Home Information Changes | ||
| 10-589 | Comprehensive Functional Assessment of Recreation | ||
| 10-590 | Comprehensive Functional Assessment of Physical Therapy | ||
| 10-592 | Comprehensive Functional Assessment of Direct Care Independent Living Skills | ||
| 10-593 | Restraint / Support Evaluation | ||
| 10-593A | Restraint / Support Evaluation Continuation | ||
| 10-594 | Comprehensive Functional Assessment of Communication | ||
| 10-595 | Comprehensive Functional Assessment of Occupational Therapy | ||
| 10-596 | Comprehensive Functional Assessment of Adult Training Programs | ||
| 10-601 | Assisted Living Facility Information Changes | ||
| 10-602 | Enhanced Services Facility Information Changes | ||
| 10-603 | Nursing Home Information Changes | ||
| 10-604 | Supported Living Information Changes (Residential Care Services) | ||
| 10-605 | ICF / IID Information Changes (Residential Care Services) | ||
| 10-611 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services) | ||
| 10-613 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Observation(Residential Care Services) | ||
| 10-614 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services) | ||
| 10-615 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Family / Representative / Collateral Contact Interview (Residential Care Services) | ||
| 10-616 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Interview (Residential Care Services) | ||
| 10-617 | Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services) | ||
| 10-617A | Certified Community Residential Services and Supports (CCRSS) Group Training Home (GTH) Home Environment and Safety Worksheet | ||
| 10-618 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services) | ||
| 10-619 | Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (Residential Care Services) | ||
| 10-620 | Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services) | ||
| 10-621 | Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services) | ||
| 10-622 | Certified Community Residential Services and Supports (CCRSS) Group Training Home Food Service Observations and Interviews (Residential Care Services) | ||
| 10-625 | State Task Checklist (Aging and Long-Term Support Administration) | ||
| 10-626 | Staffing Pattern (Aging and Long-Term Support Administration) | ||
| 10-627 | Liability Insurance Review (Aging and Long-Term Support Administration) | ||
| 10-628 | Trust Fund Review (Aging and Long-Term Support Administration) | ||
| 10-629 | Pet Record Review (Aging and Long-Term Support Administration) | ||
| 10-630 | Paid Feeding Assistant Program Review (Aging and Long-Term Support Administration) | ||
| 10-631 | Staff Qualification and Background Review (Aging and Long-Term Support Administration) | ||
| 10-632 | TB Testing Review for Staff (Aging and Long-Term Support Administration) | ||
| 10-633 | TB Testing Review for Resident (Aging and Long-Term Support Administration) | ||
| 10-634 | Medication Assistant Endorsement (Aging and Long-Term Support Administration) | ||
| 10-635 | Residential Transition Exchange of Information (Developmental Disabilities Administration) | ||
| 10-638 | AFH Meaningful Day - Monthly Activities and Challenging Behavior Log | ||
| 10-641 | Community Instructor Qualification Tool (Home and Community Services) | ||
| 10-642 | Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services) | ||
| 10-643 | PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration) | ||
| 10-648 | Planned Action Notice PASRR Determination Supporting Information (Pre-Admission Screening and Resident Review) (Developmental Disabilities Administration) | ||
| 10-650 | Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 10-650A | Adult Family Home (AFH) Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 10-653 | State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application | ||
| 10-656 | Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration) | ||
| 10-656 | Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration) | ||
| 10-658 | Specialized Habilitation 90-Day (Quarterly) Report (Developmental Disabilities Administration) | ||
| 10-660 | Community Engagement 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration) | ||
| 10-661 | Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration) | ||
| 10-661 | Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration) | ||
| 10-662 | Equine Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration) | ||
| 10-662 | Equine Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration) | ||
| 10-664 | New or Update Provider Information Worksheet (Developmental Disabilities Administration) | ||
| 10-666 | Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration) | ||
| 10-669 | Out-of-Home Services (OHS) Transition Checklist (Developmental Disabilities Administrations) | ||
| 10-670 | Nursing Home Facility License Application (Aging and Long-Term Support Administration) | ||
| 10-671 | Intensive Habilitation Services for Children Certification Evaluation (Developmental Disabilities Administration) | ||
| 10-673 | Request for ICF/IID or SONF Services at an RHC Administration Application | ||
| 10-676 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Finances Record Review | ||
| 10-677 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Record Review | ||
| 11-019 | Vocational Information (Division of Vocational Rehabilitation) | ||
| 11-022 | Application for Vocational Rehabilitation Services |
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| 11-030 | Service Delivery Outcome Report (Community Rehabilitation Program - CRP) | ||
| 11-058 | Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation) | ||
| 11-066 | Assistive Communication Technology Request (Office of Deaf and Hard of Hearing) | ||
| 11-067 | Monthly Budget Worksheet (Division of Vocational Rehabilitation) | ||
| 11-068 | DVR Internship Application (Division of Vocational Rehabilitation) | ||
| 11-068 | Customer Internship Program Internship Application (Division of Vocational Rehabilitation) |
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| 11-069 | DVR Internship Agreement (Division of Vocational Rehabilitation) |
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| 11-070 | DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation) | ||
| 11-071 | DVR Employer Expense Worksheet (Division of Vocational Rehabilitation) | ||
| 11-084 | Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation) | ||
| 11-088 | DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet | ||
| 11-097 | Service Delivery Outcome Report (Independent Living Services - IL) | ||
| 11-098 | Vocational Assessment Worksheet |
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| 11-106 | Pre-ETS (Pre-Employment Transition Services) Self-Advocacy Training (Division of Vocational Rehabilitation) | ||
| 11-107 | Pre-ETS (Pre-Employment Transition Services) Peer Mentoring (Division of Vocational Rehabilitation) | ||
| 11-110 | Pre-ETS (Pre-Employment Transition Services) Informational Interview (Division of Vocational Rehabilitation) | ||
| 11-112 | Pre-ETS (Pre-Employment Transition Services) Job Shadow (Division of Vocational Rehabilitation) | ||
| 11-114 | Student Workshop Roster | ||
| 11-118 | Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation) | ||
| 11-119 | Informational Interview Worksheet (Division of Vocational Rehabilitation) | ||
| 11-132 | 90 Day Review (Division of Vocational Rehabilitation) | ||
| 11-133 | Jobs and Training Inventory (Division of Vocational Rehabilitation) | ||
| 11-134 | Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation) | ||
| 11-146 | Supported Employment Referral (Economic Services Administration) |
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| 11-149 | Division of Vocational Rehabilitation (DVR) Customer Job Seeker Accommodation Worksheet | ||
| 11-152 | Forensic Navigator to Inpatient - Referral Information Form (RIF) (Office of Forensic Mental Health Services) | ||
| 11-153 | Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services) | ||
| 11-154 | Personal Pathway | ||
| 11-163 | Applicant Certification and Assurances (Division of Vocational Rehabilitation) | ||
| 11-164 | Community Rehabilitation Program (CRP) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 11-165 | Independent Living (IL) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 11-166 | Contractor Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation) | ||
| 12-206 | Application for Disaster Food Benefits | ||
| 12-207 | Application for Disaster Cash Assistance | ||
| 12-209 | Client Fraud Report | ||
| 12-210 | Medicaid Provider Fraud Report | ||
| 12-212 | Waiver of Administrative Disqualification Hearing (Community Services Division) | ||
| 13-585A | Range of Joint Motion Evaluation Chart | ||
| 13-678 Page 1 | Nurse Delegation: Consent for Delegation Process | ||
| 13-678 Page 2 | Nurse Delegation: Instructions for Nursing Task | ||
| 13-678B | Nurse Delegation: Assumption of Delegation | ||
| 13-681 | Nurse Delegation: Change in Medical Orders | ||
| 13-712 | Behavioral Health Personal Care (BHPC) Request for MCO Funding (Aging and Long-Term Support Administration) | ||
| 13-738 | DDA / DCYF Request to Cost Share (Developmental Disabilities Administration) (Department of Children, Youth, and Families) | ||
| 13-893 | Nurse Delegation: Request For Additional Units | ||
| 13-899 | Review of Medical Evidence | ||
| 13-903 | DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration) | ||
| 13-906 | Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services) | ||
| 13-915 | Information for Respite Care Service Providers: Addendum to TCARE Assessment (Aging and Long-Term Support Administration) | ||
| 13-917 | CCSS Medical / Dental Services Authorization (Community Crisis Stabilization Services) (Developmental Disabilities Administration) | ||
| 13-919 | Weekly Status Update (Competency Restoration Program) (Behavioral Rehabilitation Administration) | ||
| 13-920 | Outpatient Competency Restoration Program (OCRP) Discharge Summary | ||
| 13-925 | Request for Formulary Admission or Deletion (Behavioral Health Administration) | ||
| 13-925A | Non-Formulary Drug Use Request (Behavioral Health Administration) | ||
| 13-925B | Non-Formulary Drug Use Request for Long-Acting Injectables (LAI) (Behavioral Health Administration) | ||
| 13-926 | Forensic (6358) Consultation (Behavioral Health Administration) | ||
| 13-927 | Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration) | ||
| 13-928 | Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration) | ||
| 14-001 | Application for Cash or Food Assistance |
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| 14-050 | Statement of Health, Education, and Employment | ||
| 14-057 | Child Support Referral |
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| 14-057B | Noncustodial Parent Child Support Enforcement Application |
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| 14-057D | Child Support Referral Continuation | ||
| 14-068 | Financial Statement (Division of Vocational Rehabilitation) |
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| 14-076 | Change of Circumstances |
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| 14-105 | Interview Appointment for Applicant (Community Services Division) |
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| 14-151 | Request for DDA Eligibility Determination |
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| 14-155 | Senior Citizens Service Application | ||
| 14-223 | Statement from School | ||
| 14-224 | Statement from Landlord/Manager |
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| 14-225 | Acknowledgement of Services |
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| 14-238 | Client Income Report | ||
| 14-264 | Application for Telecommunications Equipment | ||
| 14-310 | Client Status Change Report | ||
| 14-381 | WorkFirst Individual Responsibility Plan |
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| 14-401 | Notification of Address Disclosure Request - Part 1 | ||
| 14-401A | Notification of Address Disclosure Request - Part 2 | ||
| 14-402 | Notice to Parents (WorkFirst) | ||
| 14-416 | Eligibility Review for Long Term Services and Supports |
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| 14-431 | Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration) | ||
| 14-431A | Community Crisis Stabilization Services (CCSS) Medical / Dental Services Authorization (Developmental Disabilities Administration) | ||
| 14-436 | Statement of Adult Acting in Loco Parentis (As a Parent) | ||
| 14-438 | Stop Work |
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| 14-440 | Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing) | ||
| 14-454 | Estate Recovery: Repaying the State for Medical and Long Term Services and Supports |
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| 14-459 | Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration) |
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| 14-460 | Notice of Insufficient Information (Developmental Disabilities Administration) |
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| 14-463 | Waiver Transportation Record (DDA) | ||
| 14-465 | Sources for Eligibility Information (Developmental Disabilities Administration) | ||
| 14-473 | Inventory for Client and Agency Planning (ICAP) Letter | ||
| 14-475 | Appointment Letter for Division of Child Support (DCS) Good Cause Determination |
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| 14-478 | Aged, Blind, or Disabled (ABD) Program Medical Treatment Participation |
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| 14-491 | NSA Representative Checklist forDDA Review | ||
| 14-514 | Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center | ||
| 14-515 | Notice and Finding of Responsibility | ||
| 14-517 | DSHS Letter Requesting Non Work SSN | ||
| 14-520 | Your DSHS Cash or Food Assistance Benefits |
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| 14-525 | Incapacity Review for Medical Care Services |
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| 14-527 | Substance Use Disorder Requirements (HEN Referral Program) | ||
| 14-529 | Substance Use Disorder Requirements (ABD / PWA) | ||
| 14-532 | Authorized Representative |
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| 14-535 | Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration) | ||
| 14-541 | ABAWD Requirement: Medical Report (Able Bodied Adults without Dependents) | ||
| 14-542 | Application for New Program Certification (Domestic Violence Intervention Treatment) | ||
| 14-543 | Application for Renewal Program Certification (Domestic Violence Intervention Treatment) | ||
| 14-544 | Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment) | ||
| 14-552 | TED Program Pilot Project: Application for Emergency Alerting Device KIT (Office of the Deaf and Hard of Hearing) | ||
| 15-031 | Nursing Facility Notice of Action | ||
| 15-184 | Volunteer Chore Service Referral | ||
| 15-282A | Request for Enrollment in Developmental Disabilities Administration (DDA) Home and Community Based Services (HCBS) Waiver or Request to Change from One DDA HCBS Waiver to Another | ||
| 15-290 | Notification of Annual Assessment Review and Person Centered Services Planning Meeting | ||
| 15-291 | Person Centered Service Planning and Annual Assessment Meeting |
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| 15-295 | Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration) | ||
| 15-318 | DDA Crisis Diversion Bed Referral and Intake Information | ||
| 15-342 | Notice of Exception to Rule Decision | ||
| 15-360 | Residential Services Capacity Profile | ||
| 15-365 | Community Protection Treatment Worksheet Quarterly Review | ||
| 15-366 | Change of Address | ||
| 15-379 | Staff Add-on Request for Client Specific Need (Developmental Disabilities Administration)) | ||
| 15-380 | Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration) | ||
| 15-381 | Respite Assessment Worksheet | ||
| 15-382 | Positive Behavior Support Plan (PBSP) | ||
| 15-383 | Functional Behavioral Assessment (FA) | ||
| 15-384 | Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA) | ||
| 15-385 | Provider Consent For Use of Restrictive Procedures Requiring an ETP | ||
| 15-389 | Certified Community Residential Services and Support (CCRSS) Initial Application | ||
| 15-419 | Refusal of Services Statement | ||
| 15-424 | Staffed Residential Cost of Care Adjustment Request | ||
| 15-429A | Notice of Decision on Request for School Break Personal Care Exception to Rule | ||
| 15-435 | Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration | ||
| 15-436 | Request for Adult Family Home Application Fee Waiver | ||
| 15-449 | Adult Family Home Disclosure of Charges Required by RCW 70.128.280 | ||
| 15-456 | RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
| 15-458 | Adult Family Home Notice of Transfer or Change | ||
| 15-473 | Notification of Age 18 Eligibility Expiration | ||
| 15-474 | Notification of Age 20 Eligibility Expiration | ||
| 15-483 | Notification Regarding Request to Exceed Work Week Limit (Home and Community Services) - TRANSLATIONS ONLY | ||
| 15-492 | Medicaid Transformation Demonstration Service Notice | ||
| 15-501 | Notification of Initial Assessment Request (Developmental Disabilities Administration) | ||
| 15-512 | Companion Home and Alternative Living Services Incident Report (Developmental Disabilities Administration) | ||
| 15-516 | Companion Home Quarterly Report (Developmental Disabilities Administration) | ||
| 15-517 | Application for Transition from Group Home to Group Training Home | ||
| 15-547 | Continuing Education Event Approval Application (Aging and Long-Term Support Administration) | ||
| 15-548 | Adult Family Home Administrator Training Instructor Application (Home and Community Services) | ||
| 15-549 | Community Instructor Application: DSHS Adult Education (Home and Community Services) | ||
| 15-550 | Community Instructor Application (Home and Community Services) | ||
| 15-551 | Community Instructor Training Program Application and Updates (Home and Community Services) | ||
| 15-553 | Long-Term Care Worker Basic Training Enhancement Instructions and Application (Home and Community Services) | ||
| 15-554 | Facility Instructor Application (Home and Community Services) | ||
| 15-556 | Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration) | ||
| 15-564 | Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration) | ||
| 15-568 | DDA Alternative Living Provider Orientation (Developmental Disabilities Administration) | ||
| 15-569 | Notice of Termination of Service (Developmental Disabilities Administration) | ||
| 15-572 | Enhanced Services Facility (ESF) Request for Documentation | ||
| 15-576 | Enhanced Services Facility (ESF) Other Contact Interview | ||
| 15-578 | Enhanced Services Facility (ESF) Resident Record Review | ||
| 15-579 | Enhanced Services Facility (ESF) Staff and Administrative Record Review | ||
| 15-581 | Enhanced Services Facility (ESF) Notes / Worksheets | ||
| 15-582 | Enhanced Services Facility (ESF) Exit Preparation Worksheet | ||
| 15-584 | Enhanced Services Facility (ESF) Medication Pass Worksheet | ||
| 15-585 | Enhanced Services Facility (ESF) Staff Schedule Worksheet | ||
| 15-591 | High School Home Care Aide Instructor Application (Home and Community Services) | ||
| 15-593 | 21-Day Competency Check Request (Behavioral Health Administration) | ||
| 16-072 | NonAssistance Support Enforcement Information (Division of Child Support) |
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| 16-172 | Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration |
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| 16-182 | Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration) | ||
| 16-195 | Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative |
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| 16-202 | 5-Day Investigation Report (Developmental Disabilities Administration (DDA) | ||
| 16-202A | Corrective Action Plan (5-Day Investigation) (Developmental Disabilities Administration) | ||
| 16-205 | Personal Emergency Plan Information |
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| 16-213 | Verification of Legal Status | ||
| 16-234 | Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF) | ||
| 16-234A | Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC)) | ||
| 16-243 | Community Services Office (CSO) Compliments and Concerns (Economic Services Administration) | ||
| 16-245 | Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services) |
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| 16-246 | Your rights as a client of the Developmental Disabilities Administration |
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| 16-247 | Your Rights and Responsibilities When You Receive MAC or TSOA Services Offered by ALTSA | ||
| 16-253 | For Field Staff Use: Sex Offender Notification to Home Care Agency and Consumer Directed Employer (Home and Community Services) | ||
| 16-255 | For Field Use Only: Sex Offender Notification to Facility (Home and Community Services) | ||
| 17-011 | Forms and Publications Request | ||
| 17-041 | Request for Records | ||
| 17-063 | Authorization |
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| 17-116 | AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion | ||
| 17-123 | Spoken Language Interpreter Service Appointment Record | ||
| 17-180 | Personal Information Release (Economic Services Administration) | ||
| 17-194 | Request for Mental Health Service Information | ||
| 17-208A | PRISM Access Request for Multiple Organizations | ||
| 17-211 | Authorization for SSI Facilitation Records (Economic Services Administration) | ||
| 17-226 | AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration) | ||
| 17-229 | Pre-Admission Screening and Resident Review (PASRR) Records Request | ||
| 17-230 | Non-Emergency Medical Transportation (NEMT) for PASRR Program Request | ||
| 17-231 | Mental Incapacity Evaluation (MIE) Contractor Travel Plan | ||
| 17-242 | Residential Habilitation Center (RHC) Informed Consent (Developmental Disabilities Administration) | ||
| 17-257 | Companion Home Client Budget Worksheet (Developmental Disabilities Administration) | ||
| 17-259 | Companion Home Client Inventory Record | ||
| 17-260 | Companion Home Gift Card or Pre-paid Credit Card Ledger (Developmental Disabilities Administration) | ||
| 17-261 | Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing) | ||
| 17-263 | Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation) | ||
| 17-264 | DVR Background Check Reporting (Division of Vocational Rehabilitation) | ||
| 17-265 | DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation) | ||
| 17-266 | Contractor Designated Contact(s) Background Check (Division of Vocational Rehabilitation) | ||
| 17-284 | Preferred Sign Language Interpreter List (Office of Deaf and Hard of Hearing) | ||
| 17-292 | Assistive Communication Technology (ACT) Program Service Request / Work Order for Induction Loops (Office of the Deaf and Hard of Hearing) | ||
| 17-294 | Outpatient Competency Restoration Program Clinical Screening (Behavioral Health Administration) | ||
| 17-295 | Residential Quality Assurance Certification Evaluation Checklist for Companion Homes Providers (Developmental Disabilities Administration) | ||
| 17-296 | Residential Quality Assurance Certification Evaluation Checklist for Alternative Living Providers (Developmental Disabilities Administration) | ||
| 17-297 | Removal and Transport Directive (Behavioral Health Administration) | ||
| 17-299 | Vendor Agreement Information (Behavioral Health Administration) | ||
| 17-300 | BHA Personal Information Release (Behavioral Health Administration) | ||
| 18-078 | Application for Nonassistance Support Enforcement Services |
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| 18-097 | Statement of Resources and Expenses |
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| 18-176 | Address Release Information Letter | ||
| 18-176A | Address Release Information Letter |
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| 18-235 | Initial payment (Interim Assistance Reimbursement Authorization) |
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| 18-334 | How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs |
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| 18-398A | Vendor / Provider Overpayment Notice | ||
| 18-398B | Department of Children, Youth, and Families (DCYF) Client Overpayment Notice |
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| 18-399 | Social Service Incorrect Payment Computation | ||
| 18-433 | Declaration of Support Payments (Division of Child Support) |
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| 18-463 | New Hire Reporting Methods and Instructions | ||
| 18-463 | New Hire Reporting Methods and Instructions (Division of Child Support) | ||
| 18-464 | Introduction to New Hire Reporting | ||
| 18-484 | Automatic Payment Authorization and Electronic Funds Transfer Information |
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| 18-544 | Transmittal of Resident Personal Funds | ||
| 18-551 | School Statement |
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| 18-555 | Financial Information Sheet | ||
| 18-681 | Request for Collection of Uninsured Health Care Expenses | ||
| 18-700 | Direct Deposit Authorization | ||
| 18-701 | Request for Income Information for Purposes of Entering or Enforcing a Child Support Order | ||
| 19-074 | Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation) |
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| 20-273 | Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program | ||
| 20-330 | Incident Report to DDA (Developmental Disabilities Administration) | ||
| 20-332 | Appropriate Level of Forensic Services (ALFS) Screening Tool | ||
| 20-333 | Outpatient Competency Restoration Program (OCRP) Transition Plan (Behavioral Health Administration) | ||
| 20-334 | Washington State Learning Center (LC) New Course Request (Division of Developmental Disabilities) | ||
| 21-061 | Companion Home Monthly Emergency Evacuation Practice and Water Temperature Record (Developmental Disabilities Administration) | ||
| 23-034 | Alternative Living Monthly Financial Report | ||
| 27-043 | New Contractor Intake | ||
| 27-044A | Contractor Information Update (for existing DSHS contractors) | ||
| 27-053 | Paternity Information | ||
| 27-057 | Provider Referral Letter for Children's Out-of-Home Services (Developmental Disabilities Administration) | ||
| 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 | ||
| 27-081 | Employment and Day Program Services Providers: Mandatory Reporting of Abuse, Improper Use of Restraint, Neglect, Personal or Financial Exploitation, Abandonment of a Child or Vulnerable Adult (Developmental Disability Administration) | ||
| 27-094 | Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration) | ||
| 27-096 | Permission to Share Documents for Reimbursement of Health Care Expenses | ||
| 27-110 | Applicant Request for a Copy of Background Check Information | ||
| 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 |
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| 27-143 | CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool | ||
| 27-144 | CSD Disability Eligibility Review Contractor Self-Assessment Monitoring Tool | ||
| 27-156 | Notice and Consent of Communication via Text | ||
| 27-175 | DVR Additional Contractor Information (Division of Vocational Rehabilitation) | ||
| 27-176 | Release of Liability (Developmental Disabilities Administration) | ||
| 27-177 | Notice and Consent of Communication via Text | ||
| 27-179 | Adult Family Home (AFH) Informal Dispute Resolution (IDR) Request (Residential Care Services) | ||
| 27-182 | DSHS Request for Positive Identification – Thumbprint | ||
| 27-188 | Initial Opiate Prescription Informed Consent (Behavioral Health Administration) | ||
| 27-189 | Asset Verification Authorization (Home and Community Services) | ||
| 27-192 | Home and Community Services (HCS) Resumption of Training Attestation | ||
| 27-203 | Individual Provider (IP) Attestation of Informal Support (Home and Community Services) | ||
| 27-207 | Acknowledgement Statement (Meaningful Day) (Home and Community Services) | ||
| 27-209 | Nursing Home Informal Dispute Resolution Request (Residential Care Services) | ||
| 27-210 | DDA Authorization for Release of Referral Video (Developmental Disabilities Administration) |
