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
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)
27-223 Adult Family Home Policies and Procedures Attestation
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)
27-215 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 Unencrypted Email
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
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
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
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)
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)
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
18-555 Financial Information Sheet
18-551 School Statement
18-544 Transmittal of Resident Personal Funds
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information
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)
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
18-398A Vendor / Provider Overpayment Notice
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
18-235 Initial payment (Interim Assistance Reimbursement Authorization)
18-176A Address Release Information Letter
18-176 Address Release Information Letter
18-097 Statement of Resources and Expenses
18-078 Application for Nonassistance Support Enforcement Services
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
17-238 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)
17-123 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
16-273 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)
16-264 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
16-245 Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services)
16-244 New Freedom Participant Responsibility Agreement
16-243 Community Services Office (CSO) Compliments and Concerns (Economic Services Administration)
16-242 Ask DSHS
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
16-203 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)
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
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
16-107 Noncustodial Parent's Rights and Responsibilities
16-072 NonAssistance Support Enforcement Information (Division of Child Support)
15-596 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services)
15-595 Intensive Habilitation Services (IHS) Behavior Intervention Plan (Developmental Disabilities Administration)
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)
15-589C Adult Family Home (AFH) Relocation Initial Licensing Inspection (Residential Care Services)
15-589B Adult Family Home (AFH) Licensing: Resident Bedroom / Bathroom Worksheet Continuation (Residential Care Services)
15-589A Adult Family Home (AFH) LIcensing Inspection Floor Plan "Key" (Residential Care Services)
15-589 Adult Family Home (AFH) Initial Licensing Inspection (Residential Care 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)
15-494 Residential Habilitation Center (RHC) / Individual Habilitation Plan (IHP) / Individual Plan of Care (IPOC) Meeting Notification (Developmental Disabilities Administration)
15-493 PASRR Client Referral
15-492 Medicaid Transformation Project Service Notice
15-483 Notification Regarding Request to Exceed Work Week Limit (Home and Community Services) - TRANSLATIONS ONLY
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
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)
15-295 Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration)
15-291 Person Centered Service Planning and Annual Assessment Meeting
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
14-530 Disability Review
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
14-521 Your Rights (Home and Community Services)
14-520 Your DSHS Cash or Food Assistance Benefits
14-517 DSHS Letter Requesting Non Work SSN
14-515 Notice and Finding of Responsibility
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center
14-503 Interim Assistance Reimbursement Agreement Cover
14-501 Community Resource Declaration
14-495 Naturalization Letter
14-493 Requirement to Identify a Representative (Developmental Disabilities Administration)
14-492 Assessment Meeting Wrap-up
14-491 NSA Representative Checklist forDDA Review
14-489 SSIF Introduction Letter
14-484 Nurse Delegation: Nursing Visit
14-478 Aged, Blind, or Disabled (ABD) Program Medical Treatment Participation
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
14-473 Inventory for Client and Agency Planning (ICAP) Letter
14-467 Mid-Certification Review
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)
14-459 Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration)
14-454 Estate Recovery: Repaying the State for Medical and Long Term Services and Supports
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
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
14-416 Eligibility Review for Long Term Services and Supports
14-402 Notice to Parents (WorkFirst)
14-401A Notification of Address Disclosure Request - Part 2
14-401 Notification of Address Disclosure Request - Part 1
14-381 WorkFirst Individual Responsibility Plan
14-349 Protective Payee Assessment
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
14-238 Client Income Report
14-225 Acknowledgement of Services
14-224 Statement from Landlord/Manager
14-223 Statement from School
14-155 Senior Citizens Service Application
14-151 Request for DDA Eligibility Determination
14-144A Medical Disability Decision
14-113 Your Cash and Food Assistance Rights and Responsibilities
14-105 Interview Appointment for Applicant (Community Services Division)
14-084 Social Service Referral
14-078 Eligibility Review
14-076 Change of Circumstances
14-068 Financial Statement (Division of Vocational Rehabilitation)
14-057D Child Support Referral Continuation
14-057B Noncustodial Parent Child Support Enforcement Application
14-057 Child Support Referral
14-050 Statement of Health, Education, and Employment
14-012 Consent
14-001 Application for Cash or Food Assistance
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)
13-925A 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
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
11-180 Discovery Profile Report (Developmental Disabilities Administration)
11-168 Internship: Customer Evaluation
11-167 Internship: Employer Evaluation
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)
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)
11-130 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services)
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)
11-106 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
11-019 Vocational Information (Division of Vocational Rehabilitation)
10-691 Certified Community Residential Services and Supports (CCRSS) Client Characteristics (Residential Care Services)
10-690 Nursing Care Consultant Transition Tool (Developmental Disabilities Administration)
10-689 Assisted Living Facility Monitoring Visit (Residential Care Services)
10-688 DDA Specialty Adult Family Home (AFH) Pilot Monthly Client Goal and Progress Report (Developmental Disabilities Administration)
10-687 DDA Specialty Adult Family Home (AFH) Pilot: Strengths, Abilities, Interests, Learn (SAIL) (Developmental Disabilities Administration)
10-685 Companion Home Provider Supplemental Information (Developmental Disabilities Administration)
10-683 Enhanced Services Facility (ESF) Follow-Up (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)
10-661 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)
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
10-592 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)
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
10-403 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
10-377 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 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)
10-329 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)