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 | |
|---|---|---|---|
| 06-159 | Specialized Evaluation and Consultation Provider Invoice (Developmental Disabilities Administration) | ||
| 06-159A | Specialized Evaluation and Treatment Provider Invoice (Developmental Disabilities Administration) | ||
| 06-162 | Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral | ||
| 06-168 | AFH Change in Licensed Bed Capacity - Increase (Adult Family Home) (Residential Care Services) | ||
| 06-169 | AFH Change in Licensed Bed Capacity - Decrease (Adult Family Home) (Residential Care Services) | ||
| 06-171 | Funding and Expenditure Data (Tribal) | ||
| 06-172 | Domestic Violence Prevention Account | ||
| 06-173 | Medical Evidence Reimbursement | ||
| 06-176 | Assisted Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms | ||
| 06-177 | Residential Training Roster / Reimbursement (Developmental Disabilities Administration) | ||
| 06-184 | Adult Family Home (AFH) Capacity Increase Working Papers (Residential Care Services) | ||
| 06-186 | Financial Solvency Information (Aging and Long-Term Support Administration) | ||
| 06-188 | Adult Protective Services (APS) Investigations Fact Sheet (Aging and Long-Term Support Administration) |
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| 06-189 | Notice of Suspension of Supported Living Services (Developmental Disabilities Administration) | ||
| 06-191 | DPI College Financial Aid Request (Division of Program Integrity) | ||
| 06-192 | DPI Dividend and Interest Request (Division of Program Integrity) | ||
| 06-193 | DPI Statement of Shared Housing Costs (Division of Program Integrity) | ||
| 06-194 | DPI Statement of Earnings (Division of Program Integrity) | ||
| 06-195 | DPI Statement of Income (Division of Program Integrity) | ||
| 06-196 | DPI Tribal Income Verification (Division of Program Integrity) | ||
| 06-199 | Specialized Evaluation and Consultation Quarterly Report (Developmental Disabilities Administration) n | ||
| 06-200 | Registered Nurse (RN) Delegation Billing | ||
| 07-081 | Participation Reimbursement | ||
| 07-098 | Self Employment Monthly Sales and Expense Worksheet |
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| 07-103 | Basic Food Employment and Training (BFET) Participant Reimbursement |
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