Electronic DSHS Forms

You may download some DSHS forms. These are provided only if a DSHS program requests forms to be available electronically for public use. DSHS forms are available for electronic completion in different software; however, all DSHS forms below are available as Adobe Acrobat PDF files. This means you can open, view, and print each form. To open, view, and print PDF forms, you need to download the free Adobe Acrobat Reader.

We do our best to ensure the links below are accurate; but, if you find a link which does not work, please contact Forms and Records Management.

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Number Form Name(asc) File Format
15-492 Medicaid Transformation Project Service Notice
05-255 Medicaid Transformation Project Notice of Action Exception to Rule
12-210 Medicaid Provider Fraud Report
27-240 Medicaid Provider Disclosure Statement for Nursing Facility
27-094 Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration)
10-636 Meaningful Day Monthly Calendar
10-672 Meaningful Day Eligibility Checklist (Home and Community Services)
10-637 Meaningful Activity Plan (MAP) Discovery
27-076 Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
10-438 Long-Term Care Partnership (LTCP) Asset Designation
19-074 Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation)
10-505 Limitation Extension Task Explanation
10-504 Limitation Extension Request for Clients Under Age 21
10-506 Limitation Extension Request Checklist
10-503 Limitation Extension Evaluation
10-627 Liability Insurance Review (Aging and Long-Term Support Administration)
14-300 Level One Pre-Admission Screening and Resident Review (PASRR)
05-258 Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment
11-133 Jobs and Training Inventory (Division of Vocational Rehabilitation)
14-550 Job Foundation Application (Developmental Disabilities Administration)
13-927 Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration)
14-473 Inventory for Client and Agency Planning (ICAP) Letter
18-464 Introduction to New Hire Reporting
14-105 Interview Appointment for Applicant (Community Services Division)
11-167 Internship: Employer Evaluation