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
14-529 Substance Use Disorder Requirements (ABD / PWA)
14-530 Disability Review
14-532 Authorized Representative
14-534 SDCP Eligibility Checklist (Home and Community Services)
14-535 Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration)
14-538 Pre-Admission Screening and Resident Review (PASRR) Addendum
14-541 ABAWD Requirement: Medical Report (Able Bodied Adults without Dependents)
14-542 Application for New Program Certification (Domestic Violence Intervention Treatment)
14-543 Application for Renewal Program Certification (Domestic Violence Intervention Treatment)
14-544 Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment)
14-547 Continuing Care Retirement Community (CCRC) Registration Application
14-549 DDA Companion Home Provider Application (Developmental Disabilities Administration)
14-550 Job Foundation Application (Developmental Disabilities Administration)
14-551 Adult Family Homes (AFH) State Civil Penalty Reinvestment Program Grant Application
14-552 TED Program Pilot Project: Application for Emergency Alerting Device KIT (Office of the Deaf and Hard of Hearing)
14-553 High School Home Care Aide Training Program and Instructor Application and Updates (Aging and Long-Term Support Administration)
14-554 Household Application for Sun Bucks
15-031 Nursing Facility Notice of Action
15-184 Volunteer Chore Service Referral
15-215 AFH Quality Improvement Visit Assessment
15-274 Assistance Available Schedule (DDA)
15-290 Notification of Annual Assessment Review and Person Centered Services Planning Meeting
15-291 Person Centered Service Planning and Annual Assessment Meeting
15-295 Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration)
15-304 HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration)