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 | Form Name(desc) | File Format | |
|---|---|---|---|
| 11-163 | Applicant Certification and Assurances (Division of Vocational Rehabilitation) | ||
| 15-593 | 21-Day Competency Check Request (Behavioral Health Administration) | ||
| 16-202 | 5-Day Investigation Report (Developmental Disabilities Administration (DDA) | ||
| 11-132 | 90 Day Review (Division of Vocational Rehabilitation) | ||
| 17-226 | AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration) | ||
| 14-541 | ABAWD Requirement: Medical Report (Able Bodied Adults without Dependents) | ||
| 14-526 | ABD and HEN Referral Substance Use Treatment Verification | ||
| 01-205 | Able Bodied Adults Without Dependents (ABAWD) Activity Report | ||
| 14-225 | Acknowledgement of Services |
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| 27-207 | Acknowledgement Statement (Meaningful Day) (Home and Community Services) | ||
| 05-262 | Add or Remove a Service for an Existing DVIT Certification (Domestic Violence Intervention Treatment) | ||
| 05-261 | Add, Change, or Remove Direct Service Staff for a Certified DVIT Program (Domestic Violence Intervention Treatment) | ||
| 02-634 | Additional Information Needed for ILP TANF | ||
| 10-389A | Additional Room List For Assisted Living Facilities (ALF) | ||
| 18-176 | Address Release Information Letter | ||
| 18-176A | Address Release Information Letter |
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| 14-299 | Adult Assessment Referral (Economic Services Administration) | ||
| 10-580 | Adult Day Services Referral | ||
| 00-411 | Adult Family Home (AFH) Assisted Living Facility (ALF) Enhanced Services Facility (ESF) Community Program Infection Prevention and Control (IPC) Assessment Pathway (Residential Care Services) | ||
| 06-184 | Adult Family Home (AFH) Capacity Increase Working Papers (Residential Care Services) | ||
| 21-065 | Adult Family Home (AFH) Emergency Evacuation Drill | ||
| 27-179 | Adult Family Home (AFH) Informal Dispute Resolution (IDR) Request (Residential Care Services) | ||
| 02-709 | Adult Family Home (AFH) Personnel Changes (Aging and Long-Term Support Administration) | ||
| 10-650A | Adult Family Home (AFH) Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 10-422 | Adult Family Home (AFH) Quality Improvement Initial Visit | ||
| 10-231 | Adult Family Home (AFH) Referral Checklist (DDA) | ||
| 15-558 | Adult Family Home (AFH) Resident Significant Change Assessment Request | ||
| 15-548 | Adult Family Home Administrator Training Instructor Application (Home and Community Services) | ||
| 10-417 | Adult Family Home Caregiver Experience Attestation (CEA) | ||
| 15-449 | Adult Family Home Disclosure of Charges Required by RCW 70.128.280 | ||
| 10-508 | Adult Family Home Disclosure of Services Required by RCW 70.128.280 | ||
| 10-585 | Adult Family Home Information Changes | ||
| 13-645 | Adult Family Home Injuries and Accidents Log | ||
| 10-410 | Adult Family Home License Application | ||
| 10-412 | Adult Family Home License Relinquishment Letter | ||
| 15-458 | Adult Family Home Notice of Transfer or Change | ||
| 15-559 | Adult Family Home Referral Request (Developmental Disabilities Administration) | ||
| 02-516 | Adult Family Home Resident Personal Belongings Inventory (Residential Care Services) | ||
| 14-551 | Adult Family Homes (AFH) State Civil Penalty Reinvestment Program Grant Application | ||
| 27-178 | Adult Protective Services (APS) Administrative Hearing Request | ||
| 06-188 | Adult Protective Services (APS) Investigations Fact Sheet (Aging and Long-Term Support Administration) |
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| 05-249 | Adult Residential Care Services Notice of a Change | ||
| 09-052 | Affidavit of Forged Endorsement | ||
| 10-232A | AFH / ARC Provider Referral Letter | ||
| 06-169 | AFH Change in Licensed Bed Capacity - Decrease (Adult Family Home) (Residential Care Services) | ||
| 06-168 | AFH Change in Licensed Bed Capacity - Increase (Adult Family Home) (Residential Care Services) | ||
| 10-638 | AFH Meaningful Day - Monthly Activities and Challenging Behavior Log | ||
| 15-215 | AFH Quality Improvement Visit Assessment | ||
| 14-478 | Aged, Blind, or Disabled (ABD) Program Medical Treatment Participation |
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| 03-374B | Agreement on Nondisclosure of Confidential Information - Non-Employee | ||
| 17-116 | AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion | ||
| 15-388 | Alternative Living Certification Evaluation (Developmental Disabilities Administration) | ||
| 23-034 | Alternative Living Monthly Financial Report | ||
| 10-665 | Alternative Living Provider Application (Developmental Disabilities Administration) | ||
| 10-679 | Alternative Living Provider Application, Contracting, and Certification Overview Checklist (Developmental Disabilities Administration) | ||
| 10-269 | Alternative Living Services Plan and Provider Progress Report (Developmental Disabilities Administration) | ||
| 10-269A | Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration) | ||
| 10-467 | ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services) | ||
| 15-331 | Annual Assessment Checklist (Developmental Disability Administration) | ||
| 27-110 | Applicant Request for a Copy of Background Check Information | ||
| 19-237 | Application Budget Summary (Residential Care Services) | ||
| 02-592 | Application for Approval of Interpreter and Translator Continuing Education Activity | ||
| 14-001 | Application for Cash or Food Assistance |
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| 10-413 | Application For Contract For Currently Licensed Assisted Living Facility | ||
| 12-207 | Application for Disaster Cash Assistance | ||
| 12-206 | Application for Disaster Food Benefits | ||
| 14-542 | Application for New Program Certification (Domestic Violence Intervention Treatment) | ||
| 18-078 | Application for Nonassistance Support Enforcement Services |
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| 14-543 | Application for Renewal Program Certification (Domestic Violence Intervention Treatment) | ||
| 14-264 | Application for Telecommunications Equipment | ||
| 15-517 | Application for Transition from Group Home to Group Training Home | ||
| 11-022 | Application for Vocational Rehabilitation Services |
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| 14-341 | Application to Convert Payment Services Only (PSO) Case to Full Collection Services | ||
| 14-475 | Appointment Letter for Division of Child Support (DCS) Good Cause Determination |
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| 20-332 | Appropriate Level of Forensic Services (ALFS) Screening Tool | ||
| 16-242 | Ask DSHS |
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| 14-492 | Assessment Meeting Wrap-up |
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| 27-189 | Asset Verification Authorization (Home and Community Services) | ||
| 15-274 | Assistance Available Schedule (DDA) | ||
| 06-176 | Assisted Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms | ||
| 13-692A | Assisted Living Facility (ALF) Dementia Screening Tool | ||
| 10-270 | Assisted Living Facility Admission Agreement(s) Attestation | ||
| 10-372 | Assisted Living Facility Contract Requirements - Attachment N | ||
| 10-367 | Assisted Living Facility Environmental Observations - Attachment I | ||
| 10-373 | Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O | ||
| 10-371 | Assisted Living Facility Exit Preparation Worksheet - Attachment M | ||
| 10-486 | Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration) | ||
| 10-601 | Assisted Living Facility Information Changes | ||
| 10-591 | Assisted Living Facility License Application | ||
| 10-487 | Assisted Living Facility Medication Pass Worksheet - Attachment Q | ||
| 10-370 | Assisted Living Facility Notes / Worksheet - Attachment L | ||
| 10-577 | Assisted Living Facility Other Contact Information - Attachment R | ||
| 10-366 | Assisted Living Facility Other Contact Interview - Attachment H | ||
| 16-197 | Assisted Living Facility Policies and Procedures Attestation | ||
| 10-359 | Assisted Living Facility Pre Inspection Preparation - Attachment A | ||
| 10-362 | Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D | ||
| 10-362A | Assisted Living Facility Resident Characteristic Roster and Sample Selection Addendum - Attachment D | ||
| 10-363 | Assisted Living Facility Resident Group Meeting - Attachment E | ||
| 10-365 | Assisted Living Facility Resident Interview - Attachment G | ||
| 10-361 | Assisted Living Facility Resident List - Attachment C | ||
| 10-368 | Assisted Living Facility Resident Record Review - Attachment J | ||
| 10-369 | Assisted Living Facility Staff Sample / Record Review - Attachment K | ||
| 17-261 | Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing) | ||
| 17-292 | Assistive Communication Technology (ACT) Program Service Request / Work Order for Induction Loops (Office of the Deaf and Hard of Hearing) | ||
| 11-066 | Assistive Communication Technology Request (Office of Deaf and Hard of Hearing) | ||
| 17-063 | Authorization |
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| 27-130 | Authorization for Alternate EBT Cardholder |
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| 09-415 | Authorization for Expenditure (Non-Employee) | ||
| 17-211 | Authorization for SSI Facilitation Records (Economic Services Administration) | ||
| 14-532 | Authorized Representative |
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| 18-484 | Automatic Payment Authorization and Electronic Funds Transfer Information |
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| 09-653 | Background Check Authorization | ||
| 17-263 | Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation) | ||
| 11-034B | Basic Food Eligibility Requirements: What You Need to Know |
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| 07-103 | Basic Food Employment and Training (BFET) Participant Reimbursement |
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| 27-109 | BCCU Applicant Affidavit | ||
| 13-712 | Behavioral Health Personal Care (BHPC) Request for MCO Funding (Aging and Long-Term Support Administration) | ||
| 17-300 | BHA Personal Information Release (Behavioral Health Administration) | ||
| 10-360 | Boarding Home Request for Documentation - Assisted Living Facility Request For Documentation - Attachment B | ||
| 05-272 | Case Manager Instructions Following a Hearing Decision | ||
| 15-515 | CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration) | ||
| 15-389 | Certified Community Residential Services and Support (CCRSS) Initial Application | ||
| 10-619 | Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (Residential Care Services) | ||
| 10-676 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Finances Record Review | ||
| 10-614 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services) | ||
| 10-677 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Record Review | ||
| 10-611 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services) | ||
| 10-615 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Family / Representative / Collateral Contact Interview (Residential Care Services) | ||
| 10-616 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Interview (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 | ||
| 10-622 | Certified Community Residential Services and Supports (CCRSS) Group Training Home Food Service Observations and Interviews (Residential Care Services) | ||
| 10-617 | Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services) | ||
| 00-413A | Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Notes for COVID-19 (Residential Care Services) | ||
| 00-413 | Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Tool for COVID-19 (Residential Care Services) | ||
| 00-410 | Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control Assessment (IPC) Pathway (Residential Care Services) | ||
| 10-621 | Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services) | ||
| 10-680 | Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration) | ||
| 10-620 | Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services) | ||
| 15-366 | Change of Address | ||
| 05-260 | Change of Address for an Existing DVIT Certification (Domestic Violence Intervention Treatment) | ||
| 14-076 | Change of Circumstances |
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| 03-506 | Character, Competence, and Suitability Assessment | ||
| 10-244 | Child and Family Engagement Plan (Developmental Disabilities) |
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| 10-471 | Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration) | ||
| 18-607 | Child Care Verification |
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| 09-741 | Child Support Order Review Request |
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| 14-057 | Child Support Referral |
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| 14-057D | Child Support Referral Continuation | ||
| 16-230 | Children's Residential Services | ||
| 21-059 | Children's Staffed Residential Quality Assurance Assessment | ||
| 10-649 | Children's State Operated Living Alternatives (SOLA) Certification Evaluation (Developmental Disabilities Administration) | ||
| 15-387 | Children’s Respite Application | ||
| 21-060 | Children’s State Operated Living Alternative (SOLA) Quality Assurance Assessment | ||
| 12-209 | Client Fraud Report | ||
| 14-238 | Client Income Report | ||
| 15-314 | Client Necessary Supplemental Accommodation Representative Requirement Checklist | ||
| 18-398 | Client Overpayment Notice | ||
| 15-358 | Client Referral Summary (Developmental Disabilities Administration) | ||
| 14-310 | Client Status Change Report | ||
| 05-252 | Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation) | ||
| 14-431A | Community Crisis Stabilization Services (CCSS) Medical / Dental Services Authorization (Developmental Disabilities Administration) | ||
| 10-660 | Community Engagement Quarterly Progress Report (Developmental Disabilities Administration) |
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| 01-218 | Community Inclusion Rate Adjustment for Staffed Residential Rate | ||
| 15-550 | Community Instructor Application (Home and Community Services) | ||
| 15-549 | Community Instructor Application: DSHS Adult Education (Home and Community Services) | ||
| 02-692 | Community Instructor Class List Tracking Log | ||
| 10-641 | Community Instructor Qualification Tool (Home and Community Services) | ||
| 05-268 | Community Instructor Self-Assessment (Home and Community Services) | ||
| 05-269 | Community Instructor Self-Assessment for Contract Renewal and/or for Newly Established Contracts (Home and Community Services) | ||
| 15-551 | Community Instructor Training Program Application and Updates (Home and Community Services) | ||
| 10-348 | Community Protection Program Information Checklist and Risk Assessment Consent (Developmental Disabilities Administration) | ||
| 15-365 | Community Protection Treatment Worksheet Quarterly Review | ||
| 11-164 | Community Rehabilitation Program (CRP) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 10-613 | Community Residential Services and Supports (CCRSS) Certification Evaluation Client Supports Observation (Residential Care Services) | ||
| 14-501 | Community Resource Declaration | ||
| 23-045 | Community Services Division (CSD) Financial Confidence Wheel (Economic Services Division) | ||
| 16-243 | Community Services Office (CSO) Compliments and Concerns (Economic Services 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) | ||
| 09-995 | Companion Home Certification Evaluation (Developmental Disabilities Administration) | ||
| 17-257 | Companion Home Client Budget Worksheet (Developmental Disabilities Administration) | ||
| 17-258 | Companion Home Client Cash Ledger (Developmental Disabilities Administration) | ||
| 17-259 | Companion Home Client Inventory Record | ||
| 17-260 | Companion Home Gift Card or Pre-paid Credit Card Ledger (Developmental Disabilities Administration) | ||
| 21-061 | Companion Home Monthly Emergency Evacuation Practice and Water Temperature Record (Developmental Disabilities Administration) | ||
| 02-589 | Companion Home Outside Employment Notification and Review (Developmental Disabilities Administration) | ||
| 17-262 | Companion Home Physical and Safety Requirements Review (Developmental Disabilities Administration) | ||
| 15-516 | Companion Home Quarterly Report (Developmental Disabilities Administration) | ||
| 27-194 | Complimentary Therapies Agreement (Developmental Disabilities Administration) | ||
| 27-194 | Complimentary Therapies Agreement (Developmental Disabilities Administration) | ||
| 10-642 | Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services) | ||
| 10-596 | Comprehensive Functional Assessment of Adult Training Programs | ||
| 10-594 | Comprehensive Functional Assessment of Communication | ||
| 10-592 | Comprehensive Functional Assessment of Direct Care Independent Living Skills | ||
| 10-595 | Comprehensive Functional Assessment of Occupational Therapy | ||
| 10-590 | Comprehensive Functional Assessment of Physical Therapy | ||
| 10-589 | Comprehensive Functional Assessment of Recreation | ||
| 10-349 | Comprehensive Regional Review Tool | ||
| 10-489 | Confidential Health Information Consent Agreement |
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| 09-989 | Confidentiality Statement - Tribal Employee | ||
| 14-012 | Consent |
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| 14-547 | Continuing Care Retirement Community (CCRC) Registration Application | ||
| 15-556 | Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration) | ||
| 15-547 | Continuing Education Event Approval Application (Aging and Long-Term Support Administration) | ||
| 14-544 | Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment) | ||
| 10-415 | Contract Monitoring Checklist On-Site Review (Office of Refugee and Immigrant Assistance) | ||
| 11-084 | Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation) | ||
| 17-266 | Contractor Designated Contact(s) Background Check (Division of Vocational Rehabilitation) | ||
| 11-166 | Contractor Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation) | ||
| 27-044A | Contractor Information Update (for existing DSHS contractors) | ||
| 16-202A | Corrective Action Plan (5-Day Investigation) (Developmental Disabilities Administration) | ||
| 10-393 | Cost Estimate Worksheet for Hearing Aids and Services | ||
| 06-124 | Cost of Care Adjustment (COCA) (Developmental Disabilities) | ||
| 10-272 | Cross-System Crisis Plan (DDA) | ||
| 27-143 | CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool | ||
| 27-144 | CSD Disability Eligibility Review Contractor Self-Assessment Monitoring Tool | ||
| 15-552 | Curriculum Approval Application (Home and Community Services) | ||
| 11-068 | Customer Internship Program Internship Application (Division of Vocational Rehabilitation) |
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| 10-584 | Data Summary Report and Recommendations (Developmental Disabilities Administration) | ||
| 13-738 | DDA / DCYF Request to Cost Share (Developmental Disabilities Administration) (Department of Children, Youth, and Families) | ||
| 15-568 | DDA Alternative Living Provider Orientation (Developmental Disabilities Administration) | ||
| 27-210 | DDA Authorization for Release of Referral Video (Developmental Disabilities Administration) | ||
| 15-356 | DDA Community Protection Program Chaperone Agreement | ||
| 14-549 | DDA Companion Home Provider Application (Developmental Disabilities Administration) | ||
| 15-318 | DDA Crisis Diversion Bed Referral and Intake Information | ||
| 16-237 | DDA GovDelivery Communication Request (Developmental Disabilities Administration) | ||
| 10-331 | DDA Mortality Review Provider Report (Developmental Disabilities Administration) | ||
| 13-911 | DDA Nursing Service Referral (Developmental Disabilities Administration) | ||
| 10-583 | DDA PASRR Cover Sheet | ||
| 10-623 | DDA PASRR Significant Change Invalidation (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review) | ||
| 13-903 | DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration) | ||
| 11-134 | Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation) | ||
| 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) | ||
| 09-693 | Declaration of Lawful Custody | ||
| 18-433 | Declaration of Support Payments (Division of Child Support) |
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| 27-155 | Declaration on Commercial Purposes | ||
| 27-208 | Declaration to Adult Protective Services | ||
| 18-398B | Department of Children, Youth, and Families (DCYF) Client Overpayment Notice |
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| 18-682 | Detail Sheet – Uninsured Health Care Expenses | ||
| 18-700 | Direct Deposit Authorization | ||
| 14-432 | Direct Deposit Enrollment | ||
| 14-332 | Disability Assessment | ||
| 14-530 | Disability Review |
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| 10-351 | Disclosure of Services Required by RCW 18.20.300 | ||
| 27-220 | Disposition of Remains / Release of Body Permit (Developmental Disabilities Administration) | ||
| 12-195 | Disqualification Consent Agreement | ||
| 11-149 | Division of Vocational Rehabilitation (DVR) Customer Job Seeker Accommodation Worksheet | ||
| 06-162 | Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral | ||
| 15-435 | Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration | ||
| 10-353 | Documentation Request for Medical Condition and Residual Functional Capacity | ||
| 06-172 | Domestic Violence Prevention Account | ||
| 17-265 | DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation) | ||
| 17-227 | DSHS / HCA Systems Access Request | ||
| 17-253 | DSHS Background Check System (BCS) Access Request | ||
| 04-452A | DSHS Community Services Customer Survey (Community Services Division) | ||
| 04-452 | DSHS Community Services Survey (Community Services Division, Economic Services Administration) | ||
| 14-517 | DSHS Letter Requesting Non Work SSN | ||
| 03-387 | DSHS Notice of Privacy Practices for Client Medical Information |
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| 03-387A | DSHS Notice of Privacy Practices for Client Medical Information without Acknowledgement |
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| 03-387B | DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs | ||
| 27-182 | DSHS Request for Positive Identification – Thumbprint | ||
| 03-509 | DSHS Unpaid Intern / Volunteer Application | ||
| 02-714 | DSHS Virtual Classroom Training Application (Home and Community Services) | ||
| 02-714A | DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services) | ||
| 27-175 | DVR Additional Contractor Information (Division of Vocational Rehabilitation) | ||
| 11-070 | DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation) | ||
| 17-264 | DVR Background Check Reporting (Division of Vocational Rehabilitation) | ||
| 11-071 | DVR Employer Expense Worksheet (Division of Vocational Rehabilitation) | ||
| 11-069 | DVR Internship Agreement (Division of Vocational Rehabilitation) |
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| 11-088 | DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet | ||
| 14-078 | Eligibility Review | ||
| 14-416 | Eligibility Review for Long Term Services and Supports |
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| 14-459 | Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration) |
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| 10-640 | Emphasis on Hands-On Skills Practice: Planning Attestation (Home and Community Services) | ||
| 03-490 | Employee / Contractor Awareness IRS Safeguard Training Certification | ||
| 03-076 | Employee Personal Property Damage/Loss Claim | ||
| 18-483 | Employer Payment Identification Instructions | ||
| 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) | ||
| 14-252 | Employment Verification |
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| 11-121 | Enhanced Case Management Referral Consideration (Developmental Disabilities Administration) | ||
| 06-174 | Enhanced Rate Proposal | ||
| 15-577 | Enhanced Services Facility (ESF) Environmental Observations | ||
| 15-582 | Enhanced Services Facility (ESF) Exit Preparation Worksheet | ||
| 15-583 | Enhanced Services Facility (ESF) Food Service Observations and Interviews | ||
| 15-586 | Enhanced Services Facility (ESF) Inspection Packet | ||
| 15-584 | Enhanced Services Facility (ESF) Medication Pass Worksheet | ||
| 15-581 | Enhanced Services Facility (ESF) Notes / Worksheets | ||
| 15-576 | Enhanced Services Facility (ESF) Other Contact Interview | ||
| 15-571 | Enhanced Services Facility (ESF) Pre-Inspection Preparation | ||
| 15-572 | Enhanced Services Facility (ESF) Request for Documentation | ||
| 15-574 | Enhanced Services Facility (ESF) Resident Characteristic Roster and Sample Selection | ||
| 15-575 | Enhanced Services Facility (ESF) Resident Interview | ||
| 15-573 | Enhanced Services Facility (ESF) Resident List | ||
| 15-578 | Enhanced Services Facility (ESF) Resident Record Review | ||
| 10-683 | Enhanced Services Facility (ESF) Revisit (Residential Care Services) | ||
| 15-579 | Enhanced Services Facility (ESF) Staff and Administrative Record Review | ||
| 15-585 | Enhanced Services Facility (ESF) Staff Schedule Worksheet (Residential Care Services) | ||
| 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) | ||
| 10-535 | Enhanced Services Facility Application | ||
| 10-602 | Enhanced Services Facility Information Changes | ||
| 14-462 | Epilepsy Verification Request (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) | ||
| 03-374D | ESA Non-Dislcosure of Confidential Information Agreement - Non Employee | ||
| 14-454 | Estate Recovery: Repaying the State for Medical and Long Term Services and Supports |
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| 07-107 | Exception to Rule and Notice Guardianship Fees and Related Costs (Aging and Long-Term Support Administration and Developmental Disabilities Administration) | ||
| 10-663 | Existing Companion Home (CH) Movers Checklist (Developmental Disabilities Administration) | ||
| 10-488 | Extended Foster Care Program Consent | ||
| 15-554 | Facility Instructor Application (Home and Community Services) | ||
| 15-555 | Facility Training Program Application and Updates (Home and Community Services) | ||
| 02-528 | Fair Hearing Withdrawal |
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| 20-273 | Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program | ||
| 13-713 | Fast Track Service Agreement |
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| 05-254 | Federal Subminimum Wage Certificate Holder | ||
| 14-443 | Financial / Social Services Communication | ||
| 07-104 | Financial Communication to Social Services | ||
| 18-555 | Financial Information Sheet | ||
| 06-186 | Financial Solvency Information (Aging and Long-Term Support Administration) | ||
| 14-068 | Financial Statement (Division of Vocational Rehabilitation) |
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| 27-059 | Fingerprint Appointment |
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| 27-089 | Fingerprint-Based Background Check Notice | ||
| 16-253 | For Field Staff Use: Sex Offender Notification to Home Care Agency and Consumer Directed Employer (Home and Community Services) | ||
| 16-255 | For Field Use Only: Sex Offender Notification to Facility (Home and Community Services) | ||
| 13-926 | Forensic (6358) Consultation (Behavioral Health Administration) | ||
| 11-152 | Forensic Navigator to Inpatient - Referral Information Form (RIF) (Office of Forensic Mental Health Services) | ||
| 17-011 | Forms and Publications Request | ||
| 15-383 | Functional Behavioral Assessment (FA) | ||
| 06-171 | Funding and Expenditure Data (Tribal) | ||
| 10-442 | Goal Setting and Action Planning Worksheet | ||
| 11-153 | Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services) | ||
| 10-681 | Group Training Home (GTH) Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration) | ||
| 15-494 | Guardian / Family Response to Individual Habilitation Plan (IHP) Notification (Developmental Disabilities Administration) | ||
| 16-182 | Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration) | ||
| 15-304 | HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration) |
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| 10-468 | HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
| 13-776 | HCS / AAA Nursing Services Referral (Home and Community Services) | ||
| 10-481 | Health Action Plan (HAP) | ||
| 15-591 | High School Home Care Aide Instructor Application (Home and Community Services) | ||
| 14-553 | High School Home Care Aide Training Program and Instructor Application and Updates (Aging and Long-Term Support Administration) | ||
| 27-192 | Home and Community Services (HCS) Resumption of Training Attestation | ||
| 10-644 | Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA) |
|
|
| 27-147 | Housing Modification Property Release Agreement | ||
| 18-334 | How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs |
|
|
| 10-605 | ICF / IID Information Changes (Residential Care Services) | ||
| 10-337 | Important Information for SSP Recipients and Their Payees (DDA) | ||
| 14-525 | Incapacity Review for Medical Care Services |
|
|
| 20-330 | Incident Report to DDA (Developmental Disabilities Administration) | ||
| 11-165 | Independent Living (IL) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 15-380 | Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration) | ||
| 15-495 | Individual Habilitation Plan (IHP) (Developmental Disabilities Administration) | ||
| 15-496 | Individual Habilitation Plan (IHP) Revision (Developmental Disabilities Administration) | ||
| 16-262 | Individual Integrated Settings Checklist for Residential Providers (Optional) (Developmental Disabilities Administration) | ||
| 27-203 | Individual Provider (IP) Attestation of Informal Support (Home and Community Services) | ||
| 07-097 | Individual Provider Planned Action Notice Training / Certification (Home and Community Services) | ||
| 10-234 | Individual with Challenging Support Issues (DDA) | ||
| 10-234A | Individual with Complex Behaviors (Aging and Long-Term Support Administration) | ||
| 10-258 | Individual With Possible Community Protection Issues (Developmental Disabilities Administration) | ||
| 11-118 | Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation) | ||
| 16-195 | Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative |
|
|
| 13-915 | Information for Respite Care Service Providers: Addendum to TCARE Assessment (Aging and Long-Term Support Administration) | ||
| 10-400 | Information Request Letter |
|
|
| 11-119 | Informational Interview Worksheet (Division of Vocational Rehabilitation) | ||
| 10-329 | Informed Consent for ICAP | ||
| 10-659 | Initial Community Engagement Plan (Developmental Disabilities Administration) | ||
| 10-659 | Initial Community Engagement Plan (Developmental Disabilities Administration) | ||
| 27-188 | Initial Opiate Prescription Informed Consent (Behavioral Health Administration) | ||
| 18-235 | Initial payment (Interim Assistance Reimbursement Authorization) |
|
|
| 10-657 | Initial Specialized Habilitation Plan (Developmental Disabilities Administration) |
|
|
| 10-655 | Initial Staff and Family Consultation Plan (Developmental Disabilities Administration) |
|
|
| 10-570 | Intake and Referral | ||
| 16-218 | Intake Cover Letter to Tribes | ||
| 16-263 | Integrated Settings Provider Self-Assessment Residential Settings (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) | ||
| 10-682 | Intensive Habilitation Services (IHS) Habilitation Plan (Developmental Disabilities Administration) | ||
| 13-917 | Intensive Habilitation Services (IHS) Medical / Dental Services Authorization (Developmental Disabilities Administration) | ||
| 10-671 | Intensive Habilitation Services for Children Certification Evaluation (Developmental Disabilities Administration) | ||
| 14-503 | Interim Assistance Reimbursement Agreement Cover |
|
|
| 11-168 | Internship: Customer Evaluation | ||
| 11-167 | Internship: Employer Evaluation | ||
| 14-105 | Interview Appointment for Applicant (Community Services Division) |
|
|
| 18-464 | Introduction to New Hire Reporting | ||
| 14-473 | Inventory for Client and Agency Planning (ICAP) Letter | ||
| 13-927 | Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration) | ||
| 13-928 | Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration) | ||
| 14-550 | Job Foundation Application (Developmental Disabilities Administration) | ||
| 11-133 | Jobs and Training Inventory (Division of Vocational Rehabilitation) | ||
| 05-258 | Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment | ||
| 14-300 | Level One Pre-Admission Screening and Resident Review (PASRR) | ||
| 10-627 | Liability Insurance Review (Aging and Long-Term Support Administration) | ||
| 10-503 | Limitation Extension Evaluation | ||
| 10-506 | Limitation Extension Request Checklist | ||
| 10-504 | Limitation Extension Request for Clients Under Age 21 | ||
| 10-505 | Limitation Extension Task Explanation | ||
| 19-074 | Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation) |
|
|
| 10-438 | Long-Term Care Partnership (LTCP) Asset Designation | ||
| 27-076 | Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult | ||
| 10-637 | Meaningful Activity Plan (MAP) Discovery | ||
| 10-636 | Meaningful Day Monthly Calendar | ||
| 27-094 | Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration) | ||
| 12-210 | Medicaid Provider Fraud Report | ||
| 05-255 | Medicaid Transformation Demonstration Notice of Action Exception to Rule | ||
| 15-492 | Medicaid Transformation Demonstration Service Notice | ||
| 14-431 | Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration) | ||
| 14-144A | Medical Disability Decision |
|
|
| 06-173 | Medical Evidence Reimbursement | ||
| 17-301 | Medical Expense Examples (Community Services Division, Economic Services Administration) | ||
| 15-398 | Medically Intensive Children's Program (MICP) Application | ||
| 10-634 | Medication Assistant Endorsement (Aging and Long-Term Support Administration) | ||
| 17-231 | Mental Incapacity Evaluation (MIE) Contractor Travel Plan | ||
| 14-467 | Mid-Certification Review |
|
|
| 10-334 | Monitoring of Side Effects Scale (MOSES) (DDA) | ||
| 11-067 | Monthly Budget Worksheet (Division of Vocational Rehabilitation) | ||
| 10-661 | Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration) | ||
| 10-661 | Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration) | ||
| 14-495 | Naturalization Letter |
|
|
| 10-382 | Naturalization Services Pre-Screening | ||
| 16-201 | New Case / Resource Manager Assessment (Developmental Disabilities Administration) |
|
|
| 16-199 | New Case/Resource Manager Technology Training Checklist | ||
| 27-043 | New Contractor Intake | ||
| 16-244 | New Freedom Participant Responsibility Agreement | ||
| 18-463 | New Hire Reporting Methods and Instructions (Division of Child Support) | ||
| 10-664 | New or Update Provider Information Worksheet (Developmental Disabilities Administration) | ||
| 15-422 | No Paid Services Group |
|
|
| 17-230 | Non-Emergency Medical Transportation (NEMT) for PASRR Program Request | ||
| 13-925A | Non-Formulary Drug Use Request (Behavioral Health Administration) | ||
| 13-925B | Non-Formulary Drug Use Request for Long-Acting Injectables (LAI) (Behavioral Health Administration) | ||
| 14-440 | Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing) | ||
| 18-399A | Non-SSPS Client / Provider Overpayment AFRS Coding Computation | ||
| 16-072 | NonAssistance Support Enforcement Information (Division of Child Support) |
|
|
| 14-057B | Noncustodial Parent Child Support Enforcement Application | ||
| 16-107 | Noncustodial Parent's Rights and Responsibilities |
|
|
| 03-374E | Nondisclosure of Confidential Information Agreement for Non-Employee (eJAS Access) | ||
| 27-156 | Notice and Consent of Communication via Text |
|
|
| 27-177 | Notice and Consent of Communication via Text | ||
| 14-515 | Notice and Finding of Responsibility |
|
|
| 05-246 | Notice of Action Exception to Rule (Excluding AFH) | ||
| 05-256 | Notice of Action Exception to Rule for AFH Daily Rates | ||
| 15-429A | Notice of Decision on Request for School Break Personal Care Exception to Rule | ||
| 15-342 | Notice of Exception to Rule Decision | ||
| 14-460 | Notice of Insufficient Information (Developmental Disabilities Administration) |
|
|
| 14-535 | Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration) | ||
| 06-189 | Notice of Suspension of Supported Living Services (Developmental Disabilities Administration) | ||
| 15-569 | Notice of Termination of Service (Developmental Disabilities Administration) | ||
| 14-402 | Notice to Parents (WorkFirst) |
|
|
| 14-401 | Notification of Address Disclosure Request - Part 1 | ||
| 14-401A | Notification of Address Disclosure Request - Part 2 | ||
| 15-473 | Notification of Age 18 Eligibility Expiration | ||
| 15-474 | Notification of Age 20 Eligibility Expiration | ||
| 10-377 | Notification of Age Four (4) Eligibility Expiration- |
|
|
| 10-378 | Notification of Age Ten (10) Eligibility Expiration |
|
|
| 15-290 | Notification of Annual Assessment Review and Person Centered Services Planning Meeting | ||
| 10-301 | Notification of Eligibility Review (Developmental Disabilities Administration) |
|
|
| 15-501 | Notification of Initial Assessment Request (Developmental Disabilities Administration) | ||
| 15-483 | Notification Regarding Request to Exceed Work Week Limit (Home and Community Services) - TRANSLATIONS ONLY | ||
| 14-491 | NSA Representative Checklist forDDA Review | ||
| 16-193 | Nurse Aide Registry Inquiry (ADSA) | ||
| 10-448 | Nurse Delegation (ND) Contract Monitoring Chart Audit (Home and Community Services, Aging and Long Term Support Administration) | ||
| 01-212 | Nurse Delegation Referral and Communication | ||
| 13-678 Page 1 | Nurse Delegation: Consent for Delegation Process | ||
| 13-678 Page 2 | Nurse Delegation: Instructions for Nursing Task | ||
| 13-678B | Nurse Delegation: Assumption of Delegation | ||
| 13-681 | Nurse Delegation: Change in Medical Orders | ||
| 10-217 | Nurse Delegation: Nursing Assistant Credentials and Training | ||
| 14-484 | Nurse Delegation: Nursing Visit | ||
| 13-678A | Nurse Delegation: PRN Medication | ||
| 13-893 | Nurse Delegation: Request For Additional Units | ||
| 13-680 | Nurse Delegation: Rescinding Delegation | ||
| 06-123 | Nursing Assistant Training and Testing Reimbursement | ||
| 10-339 | Nursing Care Consultant (NCC) Assessment (DDA) | ||
| 15-031 | Nursing Facility Notice of Action | ||
| 15-565 | Nursing Home (NH) Complaint Investigation (CI) Skill Building Tool | ||
| 10-670 | Nursing Home Facility License Application (Aging and Long-Term Support Administration) | ||
| 27-209 | Nursing Home Informal Dispute Resolution Request (Residential Care Services) | ||
| 10-603 | Nursing Home Information Changes | ||
| 10-237 | Nursing Home Transfer or Discharge Notice (Residential Care Services) | ||
| 06-181 | Nursing Services Activity Report for AAAs | ||
| 06-180 | Nursing Services Activity Report for Home and Community Services (HCS) | ||
| 13-784 | Nursing Services Assessment | ||
| 13-780 | Nursing Services Basic Skin Assessment (Home and Community Services) | ||
| 17-238 | ODHH Approved Sign Language Interpreter Complaints | ||
| 05-248 | On-Site Review (Office of Refugee and Immigrant Assistance) | ||
| 15-567 | On-the-Job Facility Training Plan Application and Updates (Home and Community Services) | ||
| 10-669 | Out-of-Home Services (OHS) Transition Checklist (Developmental Disabilities Administrations) | ||
| 27-063 | Out-of-Home Services Agreement for Youth (Age 18-21) (Developmental Disabilities Administration) | ||
| 13-920 | Outpatient Competency Restoration Program (OCRP) Discharge Summary | ||
| 20-333 | Outpatient Competency Restoration Program (OCRP) Transition Plan (Behavioral Health Administration) | ||
| 17-294 | Outpatient Competency Restoration Program Clinical Screening (Behavioral Health Administration) | ||
| 10-639 | Overnight Planned Respite Services (OPRS) Certification Evaluation (Developmental Disabilities Administration) | ||
| 10-571 | Overnight Planned Respite Services Individualized Agreement | ||
| 10-630 | Paid Feeding Assistant Program Review (Aging and Long-Term Support Administration) | ||
| 07-103A | Participant Reimbursement with Interpreter Declaration | ||
| 04-449 | Participants Feedback (Domestic Violence Intervention Treatment) | ||
| 07-081 | Participation Reimbursement | ||
| 15-493 | PASRR Client Referral | ||
| 10-668 | PASRR Level 2 Evaluation and Determination (Developmental Disabilities Administration) | ||
| 10-643 | PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration) | ||
| 27-053 | Paternity Information | ||
| 10-509 | Pediatric Symptoms Checklist (PSC-17) | ||
| 27-096 | Permission to Share Documents for Reimbursement of Health Care Expenses | ||
| 15-295 | Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration) | ||
| 15-291 | Person Centered Service Planning and Annual Assessment Meeting |
|
|
| 16-205 | Personal Emergency Plan Information | ||
| 17-180 | Personal Information Release (Economic Services Administration) | ||
| 11-154 | Personal Pathway | ||
| 10-629 | Pet Record Review (Aging and Long-Term Support Administration) | ||
| 09-280B | Petition for Modification - Administrative Order |
|
|
| 00-398 | Phase 1 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services) | ||
| 00-399 | Phase 2 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services) | ||
| 16-235 | Photo Release | ||
| 13-021 | Physical Evaluation | ||
| 10-573 | Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination | ||
| 10-648 | Planned Action Notice PASRR Determination Supporting Information (Pre-Admission Screening and Resident Review) (Developmental Disabilities Administration) | ||
| 10-572 | Planned Respite Application (Developmental Disabilities Administration) | ||
| 15-382 | Positive Behavior Support Plan (PBSP) | ||
| 14-538 | Pre-Admission Screening and Resident Review (PASRR) Addendum | ||
| 17-321 | Pre-Admission Screening and Resident Review (PASRR) Equipment Purchase Request | ||
| 17-229 | Pre-Admission Screening and Resident Review (PASRR) Records Request | ||
| 11-110 | Pre-ETS (Pre-Employment Transition Services) Informational Interview (Division of Vocational Rehabilitation) | ||
| 11-112 | Pre-ETS (Pre-Employment Transition Services) Job Shadow (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) | ||
| 10-268 | Pre-Placement Agreement (Developmental Disabilities Administration) | ||
| 17-284 | Preferred Sign Language Interpreter List (Office of Deaf and Hard of Hearing) | ||
| 13-783 | Pressure Injury Assessment and Documentation (Home and Community Services) | ||
| 17-208A | PRISM Access Request for Multiple Organizations | ||
| 27-115 | Privacy Complaint | ||
| 15-594 | Private Duty Nursing (PDN) Care Plan (Aging and Long-Term Services Administration) | ||
| 10-650 | Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 05-273 | Private Duty Nursing (PDN) Pre-Contract Education Attestation (Home and Community Services) | ||
| 15-344 | Private Duty Nursing Logs and Skilled Nursing Tasks Log | ||
| 02-566 | Protected Health Information (PHI) Amendment | ||
| 14-349 | Protective Payee Assessment |
|
|
| 14-453 | Protective Payee Decision | ||
| 14-426 | Protective Payee Payment Plan, Case Assignment, and Closure Notice |
|
|
| 01-110A | Protective Payee Periodic Social Services Report | ||
| 01-110 | Protective Payee Report | ||
| 01-110C | Protective Payee Report Continuation | ||
| 15-385 | Provider Consent For Use of Restrictive Procedures Requiring an ETP | ||
| 27-123 | Provider Owned Housing Memorandum of Understanding Renter Attestation | ||
| 27-124 | Provider Owned Housing Memorandum of Understanding Residential Provider Attestation | ||
| 15-384 | Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA) | ||
| 27-057 | Provider Referral Letter for Children's Out-of-Home Services (Developmental Disabilities Administration) | ||
| 10-232 | Provider Referral Letter For Residential Services (Developmental Disabilities Administration) | ||
| 13-851 | Psychiatric Referral Summary | ||
| 13-865 | Psychological / Psychiatric Evaluation | ||
| 10-255 | Public Health Nurse (PHN) Summary and Recommendations | ||
| 10-472 | Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration) | ||
| 13-585A | Range of Joint Motion Evaluation Chart | ||
| 02-716 | Rapid Response Team 2 Request (Residential Care Services) (Aging and Long-Term Support Administration) | ||
| 00-412A | RCS (AFH, ALF, and ESF) Infection Prevention and Control (IPC) Assessment Notes for COVID-19 (Residential Care Services) (Adult Family Home, Assisted Living Facility, and Enhanced Services Facility) | ||
| 00-412 | RCS (AFH, ALF, and ESF) Infection Prevention and Control (IPC) Assessment Tool for COVID-19 (Residential Care Services) (Adult Family Home, Assisted Living Facility, and Enhanced Services Facility) | ||
| 15-456 | RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
| 10-501 | Referral to DSHS for Basic Food Employment and Training (BFET) | ||
| 15-419 | Refusal of Services Statement | ||
| 06-200 | Registered Nurse (RN) Delegation Billing | ||
| 03-077 | Release of All Claims | ||
| 27-176 | Release of Liability (Developmental Disabilities Administration) | ||
| 17-297 | Removal and Transport Directive (Behavioral Health Administration) | ||
| 03-391 | Report of Possible Client Assault | ||
| 15-436 | Request for Adult Family Home Application Fee Waiver | ||
| 10-238 | Request for an Administrative Hearing (Residential Care Services) | ||
| 10-277 | Request for Children's Out-of-Home Services (Developmental Disabilities Administration) | ||
| 18-681 | Request for Collection of Uninsured Health Care Expenses | ||
| 09-520 | Request for Conference Board |
|
|
| 14-151 | Request for DDA Eligibility Determination |
|
|
| 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 | ||
| 02-556 | Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration) | ||
| 13-925 | Request for Formulary Admission or Deletion (Behavioral Health Administration) | ||
| 05-013 | Request for Hearing |
|
|
| 10-673 | Request for ICF/IID or SONF Services at an RHC Administration Application | ||
| 18-701 | Request for Income Information for Purposes of Entering or Enforcing a Child Support Order | ||
| 10-330 | Request For Legal Advice | ||
| 17-194 | Request for Mental Health Service Information | ||
| 17-041 | Request for Records | ||
| 14-493 | Requirement to Identify a Representative (Developmental Disabilities Administration) | ||
| 15-447 | Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services) | ||
| 06-125C | Residential Allowance Request - Shelter Expense (Developmental Disabilities Administration) | ||
| 06-125B | Residential Allowance Request / Damage (Developmental Disabilities Administration) | ||
| 06-125 | Residential Allowance Request / Insufficient Income and Housemate Allowance (Developmental Disabilities Administration) | ||
| 06-125A | Residential Allowance Request / Start Up Costs (Developmental Disabilities Administration) | ||
| 10-645 | Residential Certification Evaluation Client Interview (Developmental Disabilities Administration) | ||
| 10-646 | Residential Certification Evaluation Legal Representative Interview (Developmental Disabilities Administration) | ||
| 10-647 | Residential Certification Evaluation Staff Interview (Developmental Disabilities Administration) | ||
| 17-242 | Residential Habilitation Center (RHC) Informed Consent (Developmental Disabilities Administration) | ||
| 02-632 | Residential Provider's Report of Weapon Ownership in Residential Setting | ||
| 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) | ||
| 10-666 | Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration) | ||
| 15-564 | Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration) | ||
| 05-274 | Residential Referral Transition (Developmental Disabilities Administration) | ||
| 15-360 | Residential Services Capacity Profile | ||
| 10-403 | Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult | ||
| 10-328 | Residential Site Approval Request | ||
| 06-177 | Residential Training Roster / Reimbursement (Developmental Disabilities Administration) | ||
| 10-635 | Residential Transition Exchange of Information (Developmental Disabilities Administration) | ||
| 15-381 | Respite Assessment Worksheet | ||
| 10-593 | Restraint / Support Evaluation | ||
| 10-593A | Restraint / Support Evaluation Continuation | ||
| 13-899 | Review of Medical Evidence | ||
| 05-259 | Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment) | ||
| 10-389 | Room List For Assisted Living Facilities (ALF) | ||
| 15-560 | Room Requirements Checklist (Home and Community Services) | ||
| 05-010 | Rule Exception Request | ||
| 03-133 | Safety Incident / Close Call Report | ||
| 10-427 | School District Communication | ||
| 18-551 | School Statement |
|
|
| 14-534 | SDCP Eligibility Checklist (Home and Community Services) | ||
| 07-098 | Self Employment Monthly Sales and Expense Worksheet |
|
|
| 05-267 | Self-Assessment and Monitoring Tool (Home and Community Services) | ||
| 07-042B | Self-Employment Income Report |
|
|
| 14-155 | Senior Citizens Service Application | ||
| 11-142 | Service Delivery Outcome Plan: Pre-ETS IL Skills Training | ||
| 11-123 | Service Delivery Outcome Plan: WBL - Experience A | ||
| 11-124 | Service Delivery Outcome Plan: WBL - Experience B | ||
| 11-125 | Service Delivery Outcome Plan: WBL - Experience C | ||
| 11-030 | Service Delivery Outcome Report (Community Rehabilitation Program - CRP) | ||
| 11-097 | Service Delivery Outcome Report (Independent Living Services - IL) | ||
| 10-104B | Service Verification / Attendance Record For Alternative Living Providers (Developmental Disabilities Administration) | ||
| 10-423 | Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services | ||
| 17-155 | Sign Language Interpreter Registration | ||
| 16-203 | SIS-A Rating Key (Developmental Disabilities Administration) | ||
| 16-245 | Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services) |
|
|
| 15-376 | Skin Observation Protocols | ||
| 18-399 | Social Service Incorrect Payment Computation | ||
| 14-084 | Social Service Referral | ||
| 16-191 | SOLA Vehicle Trip Log (Developmental Disabilities Administration) | ||
| 14-465 | Sources for Eligibility Information (Developmental Disabilities Administration) | ||
| 06-159 | Specialized Evaluation and Consultation Provider Invoice (Developmental Disabilities Administration) | ||
| 06-199 | Specialized Evaluation and Consultation Quarterly Report (Developmental Disabilities Administration) n | ||
