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 | |
|---|---|---|---|
| 27-220 | 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) | ||
| 27-215 | Teleservice Agreement (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) | ||
| 27-208 | Declaration to Adult Protective Services | ||
| 27-207 | Acknowledgement Statement (Meaningful Day) (Home and Community Services) | ||
| 27-203 | Individual Provider (IP) Attestation of Informal Support (Home and Community Services) | ||
| 27-194 | Complimentary Therapies Agreement (Developmental Disabilities Administration) | ||
| 27-194 | Complimentary Therapies Agreement (Developmental Disabilities Administration) | ||
| 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) | ||
| 27-178 | Adult Protective Services (APS) Administrative Hearing Request | ||
| 27-177 | Notice and Consent of Communication via Text | ||
| 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 |
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| 27-155 | Declaration on Commercial Purposes | ||
| 27-147 | Housing Modification Property Release Agreement | ||
| 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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| 27-124 | Provider Owned Housing Memorandum of Understanding Residential Provider Attestation | ||
| 27-123 | Provider Owned Housing Memorandum of Understanding Renter Attestation | ||
| 27-115 | Privacy Complaint | ||
| 27-110 | Applicant Request for a Copy of Background Check Information | ||
| 27-109 | BCCU Applicant Affidavit | ||
| 27-096 | Permission to Share Documents for Reimbursement of Health Care Expenses | ||
| 27-094 | Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration) | ||
| 27-089 | Fingerprint-Based Background Check Notice | ||
| 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) | ||
| 27-076 | Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult | ||
| 27-063 | Out-of-Home Services Agreement for Youth (Age 18-21) (Developmental Disabilities Administration) | ||
| 27-059 | Fingerprint Appointment |
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| 27-057 | Provider Referral Letter for Children's Out-of-Home Services (Developmental Disabilities Administration) | ||
| 27-053 | Paternity Information | ||
| 27-044A | Contractor Information Update (for existing DSHS contractors) | ||
| 27-043 | New Contractor Intake | ||
| 23-045 | Community Services Division (CSD) Financial Confidence Wheel (Economic Services Division) | ||
| 23-034 | Alternative Living Monthly Financial Report | ||
| 21-065 | Adult Family Home (AFH) Emergency Evacuation Drill | ||
| 21-061 | Companion Home Monthly Emergency Evacuation Practice and Water Temperature Record (Developmental Disabilities Administration) | ||
| 21-060 | Children’s State Operated Living Alternative (SOLA) Quality Assurance Assessment | ||
| 21-059 | Children's Staffed Residential Quality Assurance Assessment | ||
| 20-334 | Washington State Learning Center (LC) New Course Request (Division of Developmental Disabilities) | ||
| 20-333 | Outpatient Competency Restoration Program (OCRP) Transition Plan (Behavioral Health Administration) | ||
| 20-332 | Appropriate Level of Forensic Services (ALFS) Screening Tool | ||
| 20-330 | Incident Report to DDA (Developmental Disabilities Administration) | ||
| 20-273 | Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program | ||
| 19-237 | Application Budget Summary (Residential Care Services) | ||
| 19-074 | Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation) |
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| 18-701 | Request for Income Information for Purposes of Entering or Enforcing a Child Support Order | ||
| 18-700 | Direct Deposit Authorization | ||
| 18-682 | Detail Sheet – Uninsured Health Care Expenses | ||
| 18-681 | Request for Collection of Uninsured Health Care Expenses | ||
| 18-627 | SSP Client Overpayment Notice (State Supplementary Program) | ||
| 18-607 | Child Care Verification |
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| 18-555 | Financial Information Sheet | ||
| 18-551 | School Statement |
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| 18-544 | Transmittal of Resident Personal Funds | ||
| 18-484 | Automatic Payment Authorization and Electronic Funds Transfer Information |
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| 18-483 | Employer Payment Identification Instructions | ||
| 18-464 | Introduction to New Hire Reporting | ||
| 18-463 | New Hire Reporting Methods and Instructions (Division of Child Support) | ||
| 18-433 | Declaration of Support Payments (Division of Child Support) |
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| 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 |
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| 18-398A | Vendor / Provider Overpayment Notice |
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| 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 |
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| 18-235 | Initial payment (Interim Assistance Reimbursement Authorization) |
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| 18-176A | Address Release Information Letter |
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| 18-176 | Address Release Information Letter | ||
| 18-097 | Statement of Resources and Expenses |
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| 18-078 | Application for Nonassistance Support Enforcement Services |
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| 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) | ||
| 17-265 | DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation) | ||
| 17-264 | DVR Background Check Reporting (Division of Vocational Rehabilitation) | ||
| 17-263 | Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation) | ||
| 17-262 | Companion Home Physical and Safety Requirements Review (Developmental Disabilities Administration) | ||
| 17-261 | Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing) | ||
| 17-260 | Companion Home Gift Card or Pre-paid Credit Card Ledger (Developmental Disabilities Administration) | ||
| 17-259 | Companion Home Client Inventory Record | ||
| 17-258 | Companion Home Client Cash Ledger (Developmental Disabilities Administration) | ||
| 17-257 | Companion Home Client Budget Worksheet (Developmental Disabilities Administration) | ||
| 17-253 | DSHS Background Check System (BCS) Access Request | ||
| 17-242 | Residential Habilitation Center (RHC) Informed Consent (Developmental Disabilities Administration) | ||
| 17-238 | ODHH Approved Sign Language Interpreter Complaints | ||
| 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 | ||
| 17-227 | DSHS / HCA Systems Access 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) | ||
| 17-155 | Sign Language Interpreter Registration | ||
| 17-123 | Spoken Language Interpreter Service Appointment Record | ||
| 17-116 | AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion | ||
| 17-063 | Authorization |
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| 17-041 | Request for Records | ||
| 17-011 | Forms and Publications Request | ||
| 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) | ||
| 16-264 | Integrated Settings Survey: Residential Settings (Developmental Disabilities Administration) | ||
| 16-263 | Integrated Settings Provider Self-Assessment Residential 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) | ||
| 16-253 | For Field Staff Use: Sex Offender Notification to Home Care Agency and Consumer Directed Employer (Home and Community Services) | ||
| 16-247 | Your Rights and Responsibilities When You Receive MAC or TSOA Services Offered by ALTSA | ||
| 16-246 | Your rights as a client of the Developmental Disabilities Administration |
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| 16-245 | Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services) |
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| 16-244 | New Freedom Participant Responsibility Agreement | ||
| 16-243 | Community Services Office (CSO) Compliments and Concerns (Economic Services Administration) | ||
| 16-242 | Ask DSHS |
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| 16-237 | DDA GovDelivery Communication Request (Developmental Disabilities Administration) | ||
| 16-235 | Photo Release | ||
| 16-234A | Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC)) | ||
| 16-234 | Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF) | ||
| 16-230 | Children's Residential Services | ||
| 16-218 | Intake Cover Letter to Tribes | ||
| 16-213 | Verification of Legal Status | ||
| 16-205 | Personal Emergency Plan Information | ||
| 16-203 | SIS-A Rating Key (Developmental Disabilities Administration) | ||
| 16-202A | Corrective Action Plan (5-Day Investigation) (Developmental Disabilities Administration) | ||
| 16-202 | 5-Day Investigation Report (Developmental Disabilities Administration (DDA) | ||
| 16-201 | New Case / Resource Manager Assessment (Developmental Disabilities Administration) |
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| 16-199 | New Case/Resource Manager Technology Training Checklist | ||
| 16-197 | Assisted Living Facility Policies and Procedures Attestation | ||
| 16-195 | Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative |
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| 16-193 | Nurse Aide Registry Inquiry (ADSA) | ||
| 16-191 | SOLA Vehicle Trip Log (Developmental Disabilities Administration) | ||
| 16-182 | Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration) | ||
| 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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| 16-107 | Noncustodial Parent's Rights and Responsibilities |
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| 16-072 | NonAssistance Support Enforcement Information (Division of Child Support) |
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| 15-594 | Private Duty Nursing (PDN) Care Plan (Aging and Long-Term Services Administration) | ||
| 15-593 | 21-Day Competency Check Request (Behavioral Health Administration) | ||
| 15-591 | High School Home Care Aide Instructor Application (Home and Community Services) | ||
| 15-586 | Enhanced Services Facility (ESF) Inspection Packet | ||
| 15-585B | Enhanced Services Facility (ESF) Staff Schedule Worksheet: 12-hour Shift (Residential Care Services) | ||
| 15-585A | Enhanced Services Facility (ESF) Staff Schedule Worksheet: 8-hour Shift (Residential Care Services) | ||
| 15-585 | Enhanced Services Facility (ESF) Staff Schedule Worksheet (Residential Care Services) | ||
| 15-584 | Enhanced Services Facility (ESF) Medication Pass Worksheet | ||
| 15-583 | Enhanced Services Facility (ESF) Food Service Observations and Interviews | ||
| 15-582 | Enhanced Services Facility (ESF) Exit Preparation Worksheet | ||
| 15-581 | Enhanced Services Facility (ESF) Notes / Worksheets | ||
| 15-579 | Enhanced Services Facility (ESF) Staff and Administrative Record Review | ||
| 15-578 | Enhanced Services Facility (ESF) Resident Record Review | ||
| 15-577 | Enhanced Services Facility (ESF) Environmental Observations | ||
| 15-576 | Enhanced Services Facility (ESF) Other Contact Interview | ||
| 15-575 | Enhanced Services Facility (ESF) Resident Interview | ||
| 15-574 | Enhanced Services Facility (ESF) Resident Characteristic Roster and Sample Selection | ||
| 15-573 | Enhanced Services Facility (ESF) Resident List | ||
| 15-572 | Enhanced Services Facility (ESF) Request for Documentation | ||
| 15-571 | Enhanced Services Facility (ESF) Pre-Inspection Preparation | ||
| 15-569 | Notice of Termination of Service (Developmental Disabilities Administration) | ||
| 15-568 | DDA Alternative Living Provider Orientation (Developmental Disabilities Administration) | ||
| 15-567 | On-the-Job Facility Training Plan Application and Updates (Home and Community Services) | ||
| 15-565 | Nursing Home (NH) Complaint Investigation (CI) Skill Building Tool | ||
| 15-564 | Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration) | ||
| 15-560 | Room Requirements Checklist (Home and Community Services) | ||
| 15-559 | Adult Family Home Referral Request (Developmental Disabilities Administration) | ||
| 15-558 | Adult Family Home (AFH) Resident Significant Change Assessment Request | ||
| 15-556 | Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration) | ||
| 15-555 | Facility Training Program Application and Updates (Home and Community Services) | ||
| 15-554 | Facility Instructor Application (Home and Community Services) | ||
| 15-552 | Curriculum Approval Application (Home and Community Services) | ||
| 15-551 | Community Instructor Training Program Application and Updates (Home and Community Services) | ||
| 15-550 | Community Instructor Application (Home and Community Services) | ||
| 15-549 | Community Instructor Application: DSHS Adult Education (Home and Community Services) | ||
| 15-548 | Adult Family Home Administrator Training Instructor Application (Home and Community Services) | ||
| 15-547 | Continuing Education Event Approval Application (Aging and Long-Term Support Administration) | ||
| 15-517 | Application for Transition from Group Home to Group Training Home | ||
| 15-516 | Companion Home Quarterly Report (Developmental Disabilities Administration) | ||
| 15-515 | CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration) | ||
| 15-514 | Companion Home (CH) Client Individual Financial Plan (IFP) (Developmental Disabilities Administration) | ||
| 15-512 | Companion Home and Alternative Living Services Incident Report (Developmental Disabilities Administration) | ||
| 15-501 | Notification of Initial Assessment Request (Developmental Disabilities Administration) | ||
| 15-496 | Individual Habilitation Plan (IHP) Revision (Developmental Disabilities Administration) | ||
| 15-495 | Individual Habilitation Plan (IHP) (Developmental Disabilities Administration) | ||
| 15-494 | Guardian / Family Response to Individual Habilitation Plan (IHP) Notification (Developmental Disabilities Administration) | ||
| 15-493 | PASRR Client Referral | ||
| 15-492 | Medicaid Transformation Demonstration Service Notice | ||
| 15-483 | Notification Regarding Request to Exceed Work Week Limit (Home and Community Services) - TRANSLATIONS ONLY | ||
| 15-474 | Notification of Age 20 Eligibility Expiration | ||
| 15-473 | Notification of Age 18 Eligibility Expiration | ||
| 15-458 | Adult Family Home Notice of Transfer or Change | ||
| 15-456 | RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
| 15-449 | Adult Family Home Disclosure of Charges Required by RCW 70.128.280 | ||
| 15-447 | Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services) | ||
| 15-436 | Request for Adult Family Home Application Fee Waiver | ||
| 15-435 | Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration | ||
| 15-429A | Notice of Decision on Request for School Break Personal Care Exception to Rule | ||
| 15-424 | Staffed Residential Cost of Care Adjustment Request | ||
| 15-422 | No Paid Services Group |
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| 15-419 | Refusal of Services Statement | ||
| 15-398 | Medically Intensive Children's Program (MICP) Application | ||
| 15-389 | Certified Community Residential Services and Support (CCRSS) Initial Application | ||
| 15-388 | Alternative Living Certification Evaluation (Developmental Disabilities Administration) | ||
| 15-387 | Children’s Respite Application | ||
| 15-385 | Provider Consent For Use of Restrictive Procedures Requiring an ETP | ||
| 15-384 | Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA) | ||
| 15-383 | Functional Behavioral Assessment (FA) | ||
| 15-382 | Positive Behavior Support Plan (PBSP) | ||
| 15-381 | Respite Assessment Worksheet | ||
| 15-380 | Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration) | ||
| 15-379 | Staff Add-on Request for Client Specific Need (Developmental Disabilities Administration)) | ||
| 15-376 | Skin Observation Protocols | ||
| 15-366 | Change of Address | ||
| 15-365 | Community Protection Treatment Worksheet Quarterly Review | ||
| 15-360 | Residential Services Capacity Profile | ||
| 15-358 | Client Referral Summary (Developmental Disabilities Administration) | ||
| 15-356 | DDA Community Protection Program Chaperone Agreement | ||
| 15-344 | Private Duty Nursing Logs and Skilled Nursing Tasks Log | ||
| 15-342 | Notice of Exception to Rule Decision | ||
| 15-331 | Annual Assessment Checklist (Developmental Disability Administration) | ||
| 15-318 | DDA Crisis Diversion Bed Referral and Intake Information | ||
| 15-314 | Client Necessary Supplemental Accommodation Representative Requirement Checklist | ||
| 15-304 | HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration) |
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| 15-295 | Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration) | ||
| 15-291 | Person Centered Service Planning and Annual Assessment Meeting |
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| 15-290 | Notification of Annual Assessment Review and Person Centered Services Planning Meeting | ||
| 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 | ||
| 15-274 | Assistance Available Schedule (DDA) | ||
| 15-215 | AFH Quality Improvement Visit Assessment | ||
| 15-184 | Volunteer Chore Service Referral | ||
| 15-031 | Nursing Facility Notice of Action | ||
| 14-553 | High School Home Care Aide Training Program and Instructor Application and Updates (Aging and Long-Term Support Administration) | ||
| 14-552 | TED Program Pilot Project: Application for Emergency Alerting Device KIT (Office of the Deaf and Hard of Hearing) | ||
| 14-551 | Adult Family Homes (AFH) State Civil Penalty Reinvestment Program Grant Application | ||
| 14-550 | Job Foundation Application (Developmental Disabilities Administration) | ||
| 14-549 | DDA Companion Home Provider Application (Developmental Disabilities Administration) | ||
| 14-547 | Continuing Care Retirement Community (CCRC) Registration Application | ||
| 14-544 | Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment) | ||
| 14-543 | Application for Renewal Program Certification (Domestic Violence Intervention Treatment) | ||
| 14-542 | Application for New Program Certification (Domestic Violence Intervention Treatment) | ||
| 14-541 | ABAWD Requirement: Medical Report (Able Bodied Adults without Dependents) | ||
| 14-538 | Pre-Admission Screening and Resident Review (PASRR) Addendum | ||
| 14-535 | Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration) | ||
| 14-534 | SDCP Eligibility Checklist (Home and Community Services) | ||
| 14-532 | Authorized Representative |
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| 14-530 | Disability Review |
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| 14-529 | Substance Use Disorder Requirements (ABD / PWA) | ||
| 14-528 | Substance Use Good Cause Appointment Letter (HEN Referral) | ||
| 14-527 | Substance Use Disorder Requirements (HEN Referral Program) | ||
| 14-526 | ABD and HEN Referral Substance Use Treatment Verification | ||
| 14-525 | Incapacity Review for Medical Care Services |
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| 14-521 | Your Rights (Home and Community Services) |
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| 14-520 | Your DSHS Cash or Food Assistance Benefits |
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| 14-517 | DSHS Letter Requesting Non Work SSN | ||
| 14-515 | Notice and Finding of Responsibility |
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| 14-514 | Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center |
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| 14-503 | Interim Assistance Reimbursement Agreement Cover |
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| 14-501 | Community Resource Declaration | ||
| 14-495 | Naturalization Letter |
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| 14-493 | Requirement to Identify a Representative (Developmental Disabilities Administration) | ||
| 14-492 | Assessment Meeting Wrap-up |
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| 14-491 | NSA Representative Checklist forDDA Review | ||
| 14-489 | SSIF Introduction Letter |
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| 14-484 | Nurse Delegation: Nursing Visit | ||
| 14-478 | Aged, Blind, or Disabled (ABD) Program Medical Treatment Participation |
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| 14-475 | Appointment Letter for Division of Child Support (DCS) Good Cause Determination |
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| 14-473 | Inventory for Client and Agency Planning (ICAP) Letter | ||
| 14-467 | Mid-Certification Review |
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| 14-465 | Sources for Eligibility Information (Developmental Disabilities Administration) | ||
| 14-463 | Waiver Transportation Record (DDA) | ||
| 14-462 | Epilepsy Verification Request (Developmental Disabilities Administration) | ||
| 14-460 | Notice of Insufficient Information (Developmental Disabilities Administration) |
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| 14-459 | Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration) |
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| 14-454 | Estate Recovery: Repaying the State for Medical and Long Term Services and Supports |
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| 14-453 | Protective Payee Decision | ||
| 14-449 | Unmet Need Breakdown | ||
| 14-443 | Financial / Social Services Communication | ||
| 14-440 | Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing) | ||
| 14-439 | Washington State Combined Application Program (WASHCAP) Application | ||
| 14-438 | Stop Work |
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| 14-436 | Statement of Adult Acting in Loco Parentis (As a Parent) | ||
| 14-432 | Direct Deposit Enrollment | ||
| 14-431A | Community Crisis Stabilization Services (CCSS) Medical / Dental Services Authorization (Developmental Disabilities Administration) | ||
| 14-431 | Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration) | ||
| 14-427 | Teen Parent Living Assessment | ||
| 14-426 | Protective Payee Payment Plan, Case Assignment, and Closure Notice |
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| 14-416 | Eligibility Review for Long Term Services and Supports |
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| 14-402 | Notice to Parents (WorkFirst) |
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| 14-401A | Notification of Address Disclosure Request - Part 2 | ||
| 14-401 | Notification of Address Disclosure Request - Part 1 | ||
| 14-381 | WorkFirst Individual Responsibility Plan |
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| 14-349 | Protective Payee Assessment |
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| 14-341 | Application to Convert Payment Services Only (PSO) Case to Full Collection Services | ||
| 14-332 | Disability Assessment | ||
| 14-310 | Client Status Change Report | ||
| 14-300 | Level One Pre-Admission Screening and Resident Review (PASRR) | ||
| 14-299 | Adult Assessment Referral (Economic Services Administration) | ||
| 14-264 | Application for Telecommunications Equipment | ||
| 14-252 | Employment Verification |
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| 14-238 | Client Income Report | ||
| 14-225 | Acknowledgement of Services |
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| 14-224 | Statement from Landlord/Manager |
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| 14-223 | Statement from School | ||
| 14-155 | Senior Citizens Service Application | ||
| 14-151 | Request for DDA Eligibility Determination |
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| 14-144A | Medical Disability Decision |
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| 14-113 | Your Cash and Food Assistance Rights and Responsibilities |
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| 14-105 | Interview Appointment for Applicant (Community Services Division) |
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| 14-084 | Social Service Referral | ||
| 14-078 | Eligibility Review | ||
| 14-076 | Change of Circumstances |
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| 14-068 | Financial Statement (Division of Vocational Rehabilitation) |
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| 14-057D | Child Support Referral Continuation | ||
| 14-057B | Noncustodial Parent Child Support Enforcement Application | ||
| 14-057 | Child Support Referral |
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| 14-050 | Statement of Health, Education, and Employment | ||
| 14-012 | Consent |
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| 14-001 | Application for Cash or Food Assistance |
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| 13-936 | Stabilization, Assessment, and Intervention Services (SAIF) Eligibility and Referral (Developmental Disabilities Administration) | ||
| 13-935 | State Hospital Triage Consultation and Expedited Admission (TCEA) Request | ||
| 13-928 | Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration) | ||
| 13-927 | Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration) | ||
| 13-926 | Forensic (6358) Consultation (Behavioral Health Administration) | ||
| 13-925B | Non-Formulary Drug Use Request for Long-Acting Injectables (LAI) (Behavioral Health Administration) | ||
| 13-925A | Non-Formulary Drug Use Request (Behavioral Health Administration) | ||
| 13-925 | Request for Formulary Admission or Deletion (Behavioral Health Administration) | ||
| 13-920 | Outpatient Competency Restoration Program (OCRP) Discharge Summary | ||
| 13-919 | Weekly Status Update (Competency Restoration Program) (Behavioral Rehabilitation Administration) | ||
| 13-917 | Intensive Habilitation Services (IHS) Medical / Dental Services Authorization (Developmental Disabilities Administration) | ||
| 13-915 | Information for Respite Care Service Providers: Addendum to TCARE Assessment (Aging and Long-Term Support Administration) | ||
| 13-911 | DDA Nursing Service Referral (Developmental Disabilities Administration) | ||
| 13-906 | Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services) | ||
| 13-903 | DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration) | ||
| 13-899 | Review of Medical Evidence | ||
| 13-893 | Nurse Delegation: Request For Additional Units | ||
| 13-865 | Psychological / Psychiatric Evaluation | ||
| 13-851 | Psychiatric Referral Summary | ||
| 13-784 | Nursing Services Assessment | ||
| 13-783 | Pressure Injury Assessment and Documentation (Home and Community Services) | ||
| 13-780 | Nursing Services Basic Skin Assessment (Home and Community Services) | ||
| 13-776 | HCS / AAA Nursing Services Referral (Home and Community Services) | ||
| 13-738 | DDA / DCYF Request to Cost Share (Developmental Disabilities Administration) (Department of Children, Youth, and Families) | ||
| 13-713 | Fast Track Service Agreement |
|
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| 13-712 | Behavioral Health Personal Care (BHPC) Request for MCO Funding (Aging and Long-Term Support Administration) | ||
| 13-692A | Assisted Living Facility (ALF) Dementia Screening Tool | ||
| 13-681 | Nurse Delegation: Change in Medical Orders | ||
| 13-680 | Nurse Delegation: Rescinding Delegation | ||
| 13-678B | Nurse Delegation: Assumption of Delegation | ||
| 13-678A | Nurse Delegation: PRN Medication | ||
| 13-678 Page 2 | Nurse Delegation: Instructions for Nursing Task | ||
| 13-678 Page 1 | Nurse Delegation: Consent for Delegation Process | ||
| 13-645 | Adult Family Home Injuries and Accidents Log | ||
| 13-585A | Range of Joint Motion Evaluation Chart | ||
| 13-021 | Physical Evaluation | ||
| 12-212 | Waiver of Administrative Disqualification Hearing (Community Services Division) | ||
| 12-210 | Medicaid Provider Fraud Report | ||
| 12-209 | Client Fraud Report | ||
| 12-207 | Application for Disaster Cash Assistance | ||
| 12-206 | Application for Disaster Food Benefits | ||
| 12-195 | Disqualification Consent Agreement | ||
| 11-168 | Internship: Customer Evaluation | ||
| 11-167 | Internship: Employer Evaluation | ||
| 11-166 | Contractor Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation) | ||
| 11-165 | Independent Living (IL) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 11-164 | Community Rehabilitation Program (CRP) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 11-163 | Applicant Certification and Assurances (Division of Vocational Rehabilitation) | ||
| 11-154 | Personal Pathway | ||
| 11-153 | Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services) | ||
| 11-152 | Forensic Navigator to Inpatient - Referral Information Form (RIF) (Office of Forensic Mental Health Services) | ||
| 11-149 | Division of Vocational Rehabilitation (DVR) Customer Job Seeker Accommodation Worksheet | ||
| 11-146 | Supported Employment Referral (Economic Services Administration) |
|
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| 11-142 | Service Delivery Outcome Plan: Pre-ETS IL Skills Training | ||
| 11-134 | Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation) | ||
| 11-133 | Jobs and Training Inventory (Division of Vocational Rehabilitation) | ||
| 11-132 | 90 Day Review (Division of Vocational Rehabilitation) | ||
| 11-125 | Service Delivery Outcome Plan: WBL - Experience C | ||
| 11-124 | Service Delivery Outcome Plan: WBL - Experience B | ||
| 11-123 | Service Delivery Outcome Plan: WBL - Experience A | ||
| 11-121 | Enhanced Case Management Referral Consideration (Developmental Disabilities Administration) | ||
| 11-119 | Informational Interview Worksheet (Division of Vocational Rehabilitation) | ||
| 11-118 | Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation) | ||
| 11-114 | Student Workshop Roster | ||
| 11-112 | Pre-ETS (Pre-Employment Transition Services) Job Shadow (Division of Vocational Rehabilitation) | ||
| 11-110 | Pre-ETS (Pre-Employment Transition Services) Informational Interview (Division of Vocational Rehabilitation) | ||
| 11-107 | Pre-ETS (Pre-Employment Transition Services) Peer Mentoring (Division of Vocational Rehabilitation) | ||
| 11-106 | Pre-ETS (Pre-Employment Transition Services) Self-Advocacy Training (Division of Vocational Rehabilitation) | ||
| 11-098 | Vocational Assessment Worksheet |
|
|
| 11-097 | Service Delivery Outcome Report (Independent Living Services - IL) | ||
| 11-088 | DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet | ||
| 11-084 | Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation) | ||
| 11-071 | DVR Employer Expense Worksheet (Division of Vocational Rehabilitation) | ||
| 11-070 | DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation) | ||
| 11-069 | DVR Internship Agreement (Division of Vocational Rehabilitation) |
|
|
| 11-068 | Customer Internship Program Internship Application (Division of Vocational Rehabilitation) |
|
|
| 11-067 | Monthly Budget Worksheet (Division of Vocational Rehabilitation) | ||
| 11-066 | Assistive Communication Technology Request (Office of Deaf and Hard of Hearing) | ||
| 11-058 | Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation) | ||
| 11-034B | Basic Food Eligibility Requirements: What You Need to Know |
|
|
| 11-030 | Service Delivery Outcome Report (Community Rehabilitation Program - CRP) | ||
| 11-022 | Application for Vocational Rehabilitation Services |
|
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| 11-019 | Vocational Information (Division of Vocational Rehabilitation) | ||
| 10-683 | Enhanced Services Facility (ESF) Revisit (Residential Care Services) | ||
| 10-682 | Intensive Habilitation Services (IHS) Habilitation Plan (Developmental Disabilities Administration) | ||
| 10-681 | Group Training Home (GTH) Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration) | ||
| 10-680 | Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration) | ||
| 10-679 | Alternative Living Provider Application, Contracting, and Certification Overview Checklist (Developmental Disabilities Administration) | ||
| 10-678 | Stabilization, Assessment, and Intervention Facility (SAIF) Program Evaluation (Developmental Disabilities Administration) | ||
| 10-677 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Record Review | ||
| 10-676 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Finances Record Review | ||
| 10-673 | Request for ICF/IID or SONF Services at an RHC Administration Application | ||
| 10-671 | Intensive Habilitation Services for Children Certification Evaluation (Developmental Disabilities Administration) | ||
| 10-670 | Nursing Home Facility License Application (Aging and Long-Term Support Administration) | ||
| 10-669 | Out-of-Home Services (OHS) Transition Checklist (Developmental Disabilities Administrations) | ||
| 10-668 | PASRR Level 2 Evaluation and Determination (Developmental Disabilities Administration) | ||
| 10-666 | Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration) | ||
| 10-665 | Alternative Living Provider Application (Developmental Disabilities Administration) | ||
| 10-664 | New or Update Provider Information Worksheet (Developmental Disabilities Administration) | ||
| 10-663 | Existing Companion Home (CH) Movers Checklist (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) | ||
| 10-661 | Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration) | ||
| 10-661 | Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration) | ||
| 10-660 | Community Engagement Quarterly Progress Report (Developmental Disabilities Administration) |
|
|
| 10-659 | Initial Community Engagement Plan (Developmental Disabilities Administration) | ||
| 10-659 | Initial Community Engagement Plan (Developmental Disabilities Administration) | ||
| 10-658 | Specialized Habilitation 90-Day (Quarterly) Report (Developmental Disabilities Administration) |
|
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| 10-657 | Initial Specialized Habilitation Plan (Developmental Disabilities Administration) |
|
|
| 10-656 | Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration) |
|
|
| 10-655 | Initial Staff and Family Consultation Plan (Developmental Disabilities Administration) |
|
|
| 10-653 | State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application | ||
| 10-650A | Adult Family Home (AFH) Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 10-650 | Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 10-649 | Children's State Operated Living Alternatives (SOLA) Certification Evaluation (Developmental Disabilities Administration) | ||
| 10-648 | Planned Action Notice PASRR Determination Supporting Information (Pre-Admission Screening and Resident Review) (Developmental Disabilities Administration) | ||
| 10-647 | Residential Certification Evaluation Staff Interview (Developmental Disabilities Administration) | ||
| 10-646 | Residential Certification Evaluation Legal Representative Interview (Developmental Disabilities Administration) | ||
| 10-645 | Residential Certification Evaluation Client Interview (Developmental Disabilities Administration) | ||
| 10-644 | Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA) |
|
|
| 10-643 | PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration) | ||
| 10-642 | Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services) | ||
| 10-641 | Community Instructor Qualification Tool (Home and Community Services) | ||
| 10-640 | Emphasis on Hands-On Skills Practice: Planning Attestation (Home and Community Services) | ||
| 10-639 | Overnight Planned Respite Services (OPRS) Certification Evaluation (Developmental Disabilities Administration) | ||
| 10-638 | AFH Meaningful Day - Monthly Activities and Challenging Behavior Log | ||
| 10-637 | Meaningful Activity Plan (MAP) Discovery | ||
| 10-636 | Meaningful Day Monthly Calendar | ||
| 10-635 | Residential Transition Exchange of Information (Developmental Disabilities Administration) | ||
| 10-634 | Medication Assistant Endorsement (Aging and Long-Term Support Administration) | ||
| 10-633 | TB Testing Review for Resident (Aging and Long-Term Support Administration) | ||
| 10-632 | TB Testing Review for Staff (Aging and Long-Term Support Administration) | ||
| 10-631 | Staff Qualification and Background Review (Aging and Long-Term Support Administration) | ||
| 10-630 | Paid Feeding Assistant Program Review (Aging and Long-Term Support Administration) | ||
| 10-629 | Pet Record Review (Aging and Long-Term Support Administration) | ||
| 10-628 | Trust Fund Review (Aging and Long-Term Support Administration) | ||
| 10-627 | Liability Insurance Review (Aging and Long-Term Support Administration) | ||
| 10-626 | Staffing Pattern (Aging and Long-Term Support Administration) | ||
| 10-625 | State Task Checklist (Aging and Long-Term Support Administration) | ||
| 10-623 | DDA PASRR Significant Change Invalidation (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review) | ||
| 10-622 | Certified Community Residential Services and Supports (CCRSS) Group Training Home Food Service Observations and Interviews (Residential Care Services) | ||
| 10-621 | Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services) | ||
| 10-620 | Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services) | ||
| 10-619 | Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (Residential Care Services) | ||
| 10-618 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services) | ||
| 10-617A | Certified Community Residential Services and Supports (CCRSS) Group Training Home (GTH) Home Environment and Safety Worksheet | ||
| 10-617 | Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services) | ||
| 10-616 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Interview (Residential Care Services) | ||
| 10-615 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Family / Representative / Collateral Contact Interview (Residential Care Services) | ||
| 10-614 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services) | ||
| 10-613 | Community Residential Services and Supports (CCRSS) Certification Evaluation Client Supports Observation (Residential Care Services) | ||
| 10-611 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services) | ||
| 10-605 | ICF / IID Information Changes (Residential Care Services) | ||
| 10-604 | Supported Living Information Changes (Residential Care Services) | ||
| 10-603 | Nursing Home Information Changes | ||
| 10-602 | Enhanced Services Facility Information Changes | ||
| 10-601 | Assisted Living Facility Information Changes | ||
| 10-596 | Comprehensive Functional Assessment of Adult Training Programs | ||
| 10-595 | Comprehensive Functional Assessment of Occupational Therapy | ||
| 10-594 | Comprehensive Functional Assessment of Communication | ||
| 10-593A | Restraint / Support Evaluation Continuation | ||
| 10-593 | Restraint / Support Evaluation | ||
| 10-592 | Comprehensive Functional Assessment of Direct Care Independent Living Skills | ||
| 10-591 | Assisted Living Facility License Application | ||
| 10-590 | Comprehensive Functional Assessment of Physical Therapy | ||
| 10-589 | Comprehensive Functional Assessment of Recreation | ||
| 10-585 | Adult Family Home Information Changes | ||
| 10-584 | Data Summary Report and Recommendations (Developmental Disabilities Administration) | ||
| 10-583 | DDA PASRR Cover Sheet | ||
| 10-580 | Adult Day Services Referral | ||
| 10-577 | Assisted Living Facility Other Contact Information - Attachment R | ||
| 10-574C | Transitional Care Planning Tracking: Part C. Post Move and Stabilization (Developmental Disabilities Administration) | ||
| 10-574B | Transitional Care Planning Tracking: Part B. Active Coordinator of Transition (ACT) (Developmental Disabilities Administration) | ||
| 10-574A | Transitional Care Planning Tracking: Part A. Transition Preparation (Developmental Disabilities Administration) | ||
| 10-574 | Transitional Care Planning Tracking (Developmental Disabilities Administration) | ||
| 10-573 | Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination | ||
| 10-572 | Planned Respite Application (Developmental Disabilities Administration) | ||
| 10-571 | Overnight Planned Respite Services Individualized Agreement | ||
| 10-570 | Intake and Referral | ||
| 10-535 | Enhanced Services Facility Application | ||
| 10-509 | Pediatric Symptoms Checklist (PSC-17) | ||
| 10-508 | Adult Family Home Disclosure of Services Required by RCW 70.128.280 | ||
| 10-506 | Limitation Extension Request Checklist | ||
| 10-505 | Limitation Extension Task Explanation | ||
| 10-504 | Limitation Extension Request for Clients Under Age 21 | ||
| 10-503 | Limitation Extension Evaluation | ||
| 10-501 | Referral to DSHS for Basic Food Employment and Training (BFET) | ||
| 10-489 | Confidential Health Information Consent Agreement |
|
|
| 10-488 | Extended Foster Care Program Consent | ||
| 10-487 | Assisted Living Facility Medication Pass Worksheet - Attachment Q | ||
| 10-486 | Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration) | ||
| 10-481 | Health Action Plan (HAP) | ||
| 10-472 | Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration) | ||
| 10-471 | Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration) | ||
| 10-468 | HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
| 10-467 | ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services) | ||
| 10-448 | Nurse Delegation (ND) Contract Monitoring Chart Audit (Home and Community Services, Aging and Long Term Support Administration) | ||
| 10-442 | Goal Setting and Action Planning Worksheet | ||
| 10-438 | Long-Term Care Partnership (LTCP) Asset Designation | ||
| 10-437 | Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility | ||
| 10-427 | School District Communication | ||
| 10-424 | Voluntary Participation Statement (Developmental Disability Administration) |
|
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| 10-423 | Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services | ||
| 10-422 | Adult Family Home (AFH) Quality Improvement Initial Visit | ||
| 10-417 | Adult Family Home Caregiver Experience Attestation (CEA) | ||
| 10-415 | Contract Monitoring Checklist On-Site Review (Office of Refugee and Immigrant Assistance) | ||
| 10-413 | Application For Contract For Currently Licensed Assisted Living Facility | ||
| 10-412 | Adult Family Home License Relinquishment Letter | ||
| 10-410 | Adult Family Home License Application | ||
| 10-403 | Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult | ||
| 10-400 | Information Request Letter |
|
|
| 10-396 | SSI Letter (DDA) | ||
| 10-393 | Cost Estimate Worksheet for Hearing Aids and Services | ||
| 10-389A | Additional Room List For Assisted Living Facilities (ALF) | ||
| 10-389 | Room List For Assisted Living Facilities (ALF) | ||
| 10-382 | Naturalization Services Pre-Screening | ||
| 10-378 | Notification of Age Ten (10) Eligibility Expiration |
|
|
| 10-377 | Notification of Age Four (4) Eligibility Expiration- |
|
|
| 10-373 | Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O | ||
| 10-372 | Assisted Living Facility Contract Requirements - Attachment N | ||
| 10-371 | Assisted Living Facility Exit Preparation Worksheet - Attachment M | ||
| 10-370 | Assisted Living Facility Notes / Worksheet - Attachment L | ||
| 10-369 | Assisted Living Facility Staff Sample / Record Review - Attachment K | ||
| 10-368 | Assisted Living Facility Resident Record Review - Attachment J | ||
| 10-367 | Assisted Living Facility Environmental Observations - Attachment I | ||
| 10-366 | Assisted Living Facility Other Contact Interview - Attachment H | ||
| 10-365 | Assisted Living Facility Resident Interview - Attachment G | ||
| 10-363 | Assisted Living Facility Resident Group Meeting - Attachment E | ||
| 10-362A | Assisted Living Facility Resident Characteristic Roster and Sample Selection Addendum - Attachment D | ||
| 10-362 | Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D | ||
| 10-361 | Assisted Living Facility Resident List - Attachment C | ||
| 10-360 | Boarding Home Request for Documentation - Assisted Living Facility Request For Documentation - Attachment B | ||
| 10-359 | Assisted Living Facility Pre Inspection Preparation - Attachment A | ||
| 10-353 | Documentation Request for Medical Condition and Residual Functional Capacity | ||
| 10-351 | Disclosure of Services Required by RCW 18.20.300 | ||
| 10-349 | Comprehensive Regional Review Tool | ||
| 10-348 | Community Protection Program Information Checklist and Risk Assessment Consent (Developmental Disabilities Administration) | ||
| 10-339 | Nursing Care Consultant (NCC) Assessment (DDA) | ||
| 10-337 | Important Information for SSP Recipients and Their Payees (DDA) | ||
| 10-334 | Monitoring of Side Effects Scale (MOSES) (DDA) | ||
| 10-331 | DDA Mortality Review Provider Report (Developmental Disabilities Administration) | ||
| 10-330 | Request For Legal Advice | ||
| 10-329 | Informed Consent for ICAP | ||
| 10-328 | Residential Site Approval Request | ||
| 10-326 | Staffed Residential Rate Proposal (Developmental Disabilities Administration) | ||
| 10-301 | Notification of Eligibility Review (Developmental Disabilities Administration) |
|
|
| 10-277 | Request for Children's Out-of-Home Services (Developmental Disabilities Administration) | ||
| 10-272 | Cross-System Crisis Plan (DDA) | ||
| 10-270 | Assisted Living Facility Admission Agreement(s) Attestation | ||
| 10-269A | Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration) | ||
| 10-269 | Alternative Living Services Plan and Provider Progress Report (Developmental Disabilities Administration) | ||
| 10-268 | Pre-Placement Agreement (Developmental Disabilities Administration) | ||
| 10-258 | Individual With Possible Community Protection Issues (Developmental Disabilities Administration) | ||
| 10-255 | Public Health Nurse (PHN) Summary and Recommendations | ||
| 10-244 | Child and Family Engagement Plan (Developmental Disabilities) |
|
|
| 10-238 | Request for an Administrative Hearing (Residential Care Services) | ||
| 10-237 | Nursing Home Transfer or Discharge Notice (Residential Care Services) | ||
| 10-234A | Individual with Complex Behaviors (Aging and Long-Term Support Administration) | ||
| 10-234 | Individual with Challenging Support Issues (DDA) | ||
| 10-232A | AFH / ARC Provider Referral Letter | ||
| 10-232 | Provider Referral Letter For Residential Services (Developmental Disabilities Administration) | ||
| 10-231 | Adult Family Home (AFH) Referral Checklist (DDA) | ||
| 10-217 | Nurse Delegation: Nursing Assistant Credentials and Training | ||
| 10-210 | Staff Statement of Qualifications | ||
| 10-104B | Service Verification / Attendance Record For Alternative Living Providers (Developmental Disabilities Administration) | ||
| 09-995 | Companion Home Certification Evaluation (Developmental Disabilities Administration) | ||
| 09-989 | Confidentiality Statement - Tribal Employee | ||
| 09-741 | Child Support Order Review Request |
|
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| 09-728 | Washington State Addendum to Box 2 of Part B - Plan Administrator Response | ||
| 09-693 | Declaration of Lawful Custody |
