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
27-228 CCLS Additional Delegated Authority Request
05-272 Case Manager Instructions Following a Hearing Decision
17-300 BHA Personal Information Release (Behavioral Health Administration)
13-712 Behavioral Health Personal Care (BHPC) Request for MCO Funding (Aging and Long-Term Support Administration)
27-109 BCCU Applicant Affidavit
07-103 Basic Food Employment and Training (BFET) Participant Reimbursement
11-034B Basic Food Eligibility Requirements: What You Need to Know
12-008 Basic Food Affidavit Replacement for Household Disaster
17-263 Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation)
09-653 Background Check Authorization
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information
14-532 Authorized Representative
17-211 Authorization for SSI Facilitation Records (Economic Services Administration)
09-415 Authorization for Expenditure (Non-Employee)
27-130 Authorization for Alternate EBT Cardholder
17-063 Authorization
11-066 Assistive Communication Technology Request (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)
17-261 Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing)
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-361 Assisted Living Facility Resident List - Attachment C
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