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(desc) Form Name File Format
14-401 Notification of Address Disclosure Request - Part 1
14-401A Notification of Address Disclosure Request - Part 2
14-402 Notice to Parents (WorkFirst)
14-416 Eligibility Review for Long Term Services and Supports
14-431 Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration)
14-431A Community Crisis Stabilization Services (CCSS) Medical / Dental Services Authorization (Developmental Disabilities Administration)
14-436 Statement of Adult Acting in Loco Parentis (As a Parent)
14-438 Stop Work
14-440 Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing)
14-454 Estate Recovery: Repaying the State for Medical and Long Term Services and Supports
14-459 Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration)
14-460 Notice of Insufficient Information (Developmental Disabilities Administration)
14-463 Waiver Transportation Record (DDA)
14-465 Sources for Eligibility Information (Developmental Disabilities Administration)
14-473 Inventory for Client and Agency Planning (ICAP) Letter
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
14-478 Aged, Blind, or Disabled (ABD) Program Medical Treatment Participation
14-491 NSA Representative Checklist forDDA Review
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center
14-515 Notice and Finding of Responsibility
14-517 DSHS Letter Requesting Non Work SSN
14-520 Your DSHS Cash or Food Assistance Benefits
14-525 Incapacity Review for Medical Care Services
14-526 ABD, PWA, and HEN Referral Substance Use Disorder Treatment Verification
14-527 Substance Use Disorder Requirements (HEN Referral Program)