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(desc) | Form Name | File Format | |
|---|---|---|---|
| 01-210 | Transmittal of Client Funds from the Protective Payee | ||
| 02-556 | Request and Consent for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration) | ||
| 02-566 | Protected Health Information (PHI) Amendment | ||
| 02-592 | Application for Approval of Interpreter and Translator Continuing Education Activity | ||
| 02-611 | Statement of Understanding: Mid-Certification Review |
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| 02-632 | Residential Provider's Report of Weapon Ownership in Residential Setting | ||
| 02-740 | Office of Justice and Civil Rights Complaint Request | ||
| 02-740 | Private Duty Nursing (PDN) Time Log for the Month of (Home and Community Services) | ||
| 02-758 | Subleased Housing Memorandum of Understanding Renter Attestation (Developmental Disabilities Administration) | ||
| 02-759 | Subleased Housing Memorandum of Understanding Residential Provider Attestation (Developmental Disabilities Administration) | ||
| 03-077 | Release of All Claims | ||
| 03-374B | Agreement on Nondisclosure of Confidential Information - Non-Employee | ||
| 03-374D | ESA Non-Dislcosure of Confidential Information Agreement - Non Employee | ||
| 03-374E | Nondisclosure of Confidential Information Agreement for Non-Employee (eJAS Access) | ||
| 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 with Acknowledgement |
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| 03-387B | DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs |
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| 03-389A | Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790) | ||
| 03-391 | Report of Possible Client Assault | ||
| 05-248 | On-Site Review (Office of Refugee and Immigrant Assistance) | ||
| 05-249 | Adult Residential Care Services Notice of a Change | ||
| 05-252 | Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation) | ||
| 05-255 | Medicaid Transformation Project Notice of Action Exception to Rule | ||
| 05-260 | Change of Address for an Existing DVIT Certification (Domestic Violence Intervention Treatment) | ||
| 06-124 | Cost of Care Adjustment (COCA) (Developmental Disabilities) |
