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
17-260 Companion Home Gift Card or Pre-paid Credit Card Ledger (Developmental Disabilities Administration)
17-259 Companion Home Client Inventory Record
17-257 Companion Home Client Budget Worksheet (Developmental Disabilities Administration)
17-231 Mental Incapacity Evaluation (MIE) Contractor Travel Plan
17-230 Non-Emergency Medical Transportation (NEMT) for PASRR Program Request
17-229 Pre-Admission Screening and Resident Review (PASRR) Records Request
17-226 AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration)
17-211 Authorization for SSI Facilitation Records (Economic Services Administration)
17-208A PRISM Access Request for Multiple Organizations
17-194 Request for Mental Health Service Information
17-180 Personal Information Release (Economic Services Administration)
17-123 Spoken Language Interpreter Service Appointment Record
17-116 AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion
17-063 Authorization
17-041 Request for Records
17-011 Forms and Publications Request
16-276 Diversion Navigator Interview (Office of Forensic Mental Health Services (OFMHS))
16-275 Change of Circumstance: Community Behavioral Health Supports (CBHS) / 1915i (Home and Community Services)
16-274 Exhibit B: School-to-Work County Mentorship Program Monthly Tracking and Reporting (Division of Vocational Rehabilitation)
16-273 Nurse Delegation Training for Nursing Assistance and Long Term Care Workers (LTCW) (Developmental Disabilities Administration)
16-267 Integrated Settings Review for Resource Managers (Developmental Disabilities Administration)
16-266 Integrated Settings Survey: Employment or Community Inclusion Settings (Developmental Disabilities Administration)
16-265 Integrated Settings Survey: Other Settings (Developmental Disabilities Administration)
16-262 Individual Integrated Settings Checklist for Residential Providers (Optional) (Developmental Disabilities Administration)
16-255 For Field Use Only: Sex Offender Notification to Facility (Home and Community Services)