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 | |
|---|---|---|---|
| 27-240 | Medicaid Provider Disclosure Statement for Nursing Facility | ||
| 27-234 | CCLS Small Business Self-Certification Statement | ||
| 27-228 | CCLS Additional Delegated Authority Request | ||
| 27-226 | Adult Family Home Management Agreement: Attestation Information and Attachments (Residential Care Services) | ||
| 27-225 | DSHS Claim of Stolen EBT Benefits: Food (Community Services Division) |
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| 27-222 | Consent to Release and/or Use Confidential Information for Completing an Adult Home License Application | ||
| 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) | ||
| 27-210 | DDA Authorization for Release of Referral Video (Developmental Disabilities Administration) | ||
| 27-209 | Nursing Home Informal Dispute Resolution Request (Residential Care Services) | ||
| 27-207 | Acknowledgement Statement (Meaningful Day) (Home and Community Services) | ||
| 27-203 | Individual Provider (IP) Attestation of Informal Support (Home and Community Services) | ||
| 27-192 | Home and Community Services (HCS) Resumption of Training Attestation | ||
| 27-189 | Asset Verification Authorization (Home and Community Services) | ||
| 27-188 | Initial Opiate Prescription Informed Consent (Behavioral Health Administration) | ||
| 27-182 | DSHS Request for Positive Identification – Thumbprint | ||
| 27-179 | Adult Family Home (AFH) Informal Dispute Resolution (IDR) Request (Residential Care Services) | ||
| 27-176 | Release of Liability (Developmental Disabilities Administration) | ||
| 27-175 | DVR Additional Contractor Information (Division of Vocational Rehabilitation) | ||
| 27-156 | Notice and Consent of Communication via Text or Unencrypted Email |
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| 27-147A | In-Home Environmental Adaptations General Utility and Repair Property Release Agreement (Aging and Long-Term Support Administration) | ||
| 27-144 | CSD Disability Eligibility Review Contractor Self-Assessment Monitoring Tool | ||
| 27-143 | CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool | ||
| 27-130 | Authorization for Alternate EBT Cardholder |
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