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 | |
|---|---|---|---|
| 17-260 | Companion Home Gift Card or Pre-paid Credit Card Ledger (Developmental Disabilities Administration) | ||
| 17-261 | Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing) | ||
| 17-262 | Companion Home Physical and Safety Requirements Review (Developmental Disabilities Administration) | ||
| 17-263 | Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation) | ||
| 17-264 | DVR Background Check Reporting (Division of Vocational Rehabilitation) | ||
| 17-265 | DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation) | ||
| 17-266 | Contractor Designated Contact(s) Background Check (Division of Vocational Rehabilitation) | ||
| 17-284 | Preferred Sign Language Interpreter List (Office of Deaf and Hard of Hearing) | ||
| 17-292 | Assistive Communication Technology (ACT) Program Service Request / Work Order for Induction Loops (Office of the Deaf and Hard of Hearing) | ||
| 17-294 | Outpatient Competency Restoration Program Clinical Screening (Behavioral Health Administration) | ||
| 17-295 | Residential Quality Assurance Certification Evaluation Checklist for Companion Homes Providers (Developmental Disabilities Administration) | ||
| 17-296 | Residential Quality Assurance Certification Evaluation Checklist for Alternative Living Providers (Developmental Disabilities Administration) | ||
| 17-297 | Removal and Transport Directive (Behavioral Health Administration) | ||
| 17-299 | Vendor Agreement Information (Behavioral Health Administration) | ||
| 17-300 | BHA Personal Information Release (Behavioral Health Administration) | ||
| 17-301 | Medical Expense Examples (Community Services Division, Economic Services Administration) | ||
| 17-321 | Pre-Admission Screening and Resident Review (PASRR) Equipment Purchase Request | ||
| 17-337 | Personal Service Request / Standard Referral (Developmental Disabilities Administration) | ||
| 17-337 | Personal Service Request / Standard Referral (Behavioral Health Administration) | ||
| 17-345 | Transitional Care Management Exchange of Information (Developmental Disability Administration) | ||
| 18-078 | Application for Nonassistance Support Enforcement Services |
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| 18-097 | Statement of Resources and Expenses |
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| 18-176 | Address Release Information Letter | ||
| 18-176A | Address Release Information Letter |
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| 18-235 | Initial payment (Interim Assistance Reimbursement Authorization) |
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