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
16-282 Independent Informal Dispute Resolution (IIDR) Request (Residential Care Services)
16-285 RCS Nursing Home Pre-Occupancy Inspection Site Visit – Initial Findings (Residential Care Services)
16-286 RCS Nursing Home Pre-Occupancy Inspection Follow-Up Site Visit (Residential Care Services)
16-287 Pre-Occupancy Inspection Checklist (Surveyor Use) (Residential Care Services)
16-288 Pre-Occupancy Worksheet: Resident Room / Bathroom (Residential Care Services)
16-294 Pre-Occupancy Inspection Checklist (NH Administrator Use) (Residential Care Services)
17-011 Forms and Publications Request
17-041 Request for Records
17-063 Authorization
17-116 AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion
17-123 Spoken Language Interpreter Service Appointment Record
17-180 Personal Information Release (Economic Services Administration)
17-194 Request for Mental Health Service Information
17-208A PRISM Access Request for Multiple Organizations
17-211 Authorization for SSI Facilitation Records (Economic Services Administration)
17-226 AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration)
17-227 DSHS / HCA Systems Access Request
17-229 Pre-Admission Screening and Resident Review (PASRR) Records Request
17-230 Non-Emergency Medical Transportation (NEMT) for PASRR Program Request
17-231 Mental Incapacity Evaluation (MIE) Contractor Travel Plan
17-238 ODHH Approved Sign Language Interpreter Complaints
17-253 DSHS Background Check System (BCS) Access Request
17-257 Companion Home Client Budget Worksheet (Developmental Disabilities Administration)
17-258 Companion Home Client Cash Ledger (Developmental Disabilities Administration)
17-259 Companion Home Client Inventory Record