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(desc) File Format
27-220 Disposition of Remains / Release of Body Permit (Developmental Disabilities Administration)
12-195 Disqualification Consent Agreement
16-276 Diversion Navigator Interview (Office of Forensic Mental Health Services (OFMHS))
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
17-305 DPI Authorization for Release of Information (Division of Program Integrity)
06-192 DPI Dividend and Interest Request (Division of Program Integrity)
06-194 DPI Statement of Earnings (Division of Program Integrity)
06-195 DPI Statement of Income (Division of Program Integrity)
06-193 DPI Statement of Shared Housing Costs (Division of Program Integrity)
06-196 DPI Tribal Income Verification (Division of Program Integrity)
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
27-221 DSHS Claim of Stolen EBT Benefits
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
03-387A DSHS Notice of Privacy Practices for Client Medical Information with Acknowledgement
03-387B DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs
02-744 DSHS Remote Skills Training Application: Virtual Classroom (Home and Community Services)