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 | Form Name(desc) | File Format | |
|---|---|---|---|
| 17-208A | PRISM Access Request for Multiple Organizations | ||
| 27-115 | Privacy Complaint | ||
| 15-594 | Private Duty Nursing (PDN) Care Plan (Aging and Long-Term Services Administration) | ||
| 10-650 | Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 02-740 | Private Duty Nursing (PDN) Time Log for the Month of (Home and Community Services) | ||
| 15-344 | Private Duty Nursing Logs and Skilled Nursing Tasks Log | ||
| 02-566 | Protected Health Information (PHI) Amendment | ||
| 14-349 | Protective Payee Assessment |
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| 14-453 | Protective Payee Decision | ||
| 14-426 | Protective Payee Payment Plan, Case Assignment, and Closure Notice |
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| 01-110A | Protective Payee Periodic Social Services Report | ||
| 01-110 | Protective Payee Report | ||
| 01-110C | Protective Payee Report Continuation | ||
| 10-560 | Provider / Resident Manager Interview (Residential Care Services) | ||
| 15-385 | Provider Consent For Use of Restrictive Procedures Requiring an ETP | ||
| 27-123 | Provider Owned Housing Memorandum of Understanding Renter Attestation |
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| 27-124 | Provider Owned Housing Memorandum of Understanding Residential Provider Attestation | ||
| 15-384 | Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA) | ||
| 10-232 | Provider Referral Letter For Residential Services (Developmental Disabilities Administration) | ||
| 13-851 | Psychiatric Referral Summary | ||
| 13-865 | Psychological / Psychiatric Evaluation | ||
| 10-255 | Public Health Nurse (PHN) Summary and Recommendations | ||
| 10-472 | Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration) | ||
| 13-585A | Range of Joint Motion Evaluation Chart | ||
| 02-716 | Rapid Response Team 2 Request (Residential Care Services) (Aging and Long-Term Support Administration) |
