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 Form Name(asc) File Format
12-210 Medicaid Provider Fraud Report
27-240 Medicaid Provider Disclosure Statement for Nursing Facility
27-094 Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration)
27-076 Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
19-074 Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation)
10-504 Limitation Extension Request for Clients Under Age 21
10-627 Liability Insurance Review (Aging and Long-Term Support Administration)
05-258 Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment
11-133 Jobs and Training Inventory (Division of Vocational Rehabilitation)
13-927 Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration)
14-473 Inventory for Client and Agency Planning (ICAP) Letter
18-464 Introduction to New Hire Reporting
14-105 Interview Appointment for Applicant (Community Services Division)
10-671 Intensive Habilitation Services for Children Certification Evaluation (Developmental Disabilities Administration)
13-917 Intensive Habilitation Services (IHS) Medical / Dental Services Authorization (Developmental Disabilities Administration)
15-595 Intensive Habilitation Services (IHS) Behavior Intervention Plan (Developmental Disabilities Administration)
16-265 Integrated Settings Survey: Other Settings (Developmental Disabilities Administration)
16-266 Integrated Settings Survey: Employment or Community Inclusion Settings (Developmental Disabilities Administration)
16-267 Integrated Settings Review for Resource Managers (Developmental Disabilities Administration)
18-235 Initial payment (Interim Assistance Reimbursement Authorization)
27-188 Initial Opiate Prescription Informed Consent (Behavioral Health Administration)
10-329 Informed Consent for ICAP
11-119 Informational Interview Worksheet (Division of Vocational Rehabilitation)
10-400 Information Request Letter
13-915 Information for Respite Care Service Providers: Addendum to TCARE Assessment (Aging and Long-Term Support Administration)