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
17-301 Medical Expense Examples (Community Services Division, Economic Services Administration)
17-305 DPI Authorization for Release of Information (Division of Program Integrity)
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
18-097 Statement of Resources and Expenses
18-176 Address Release Information Letter
18-176A Address Release Information Letter
18-235 Initial payment (Interim Assistance Reimbursement Authorization)
18-334 How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs
18-398 Client Overpayment Notice
18-398A Vendor / Provider Overpayment Notice
18-398B Department of Children, Youth, and Families (DCYF) Client Overpayment Notice
18-399 Social Service Incorrect Payment Computation
18-399A Non-SSPS Client / Provider Overpayment AFRS Coding Computation
18-433 Declaration of Support Payments (Division of Child Support)
18-463 New Hire Reporting Methods and Instructions (Division of Child Support)
18-464 Introduction to New Hire Reporting
18-483 Employer Payment Identification Instructions
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information
18-544 Transmittal of Resident Personal Funds
18-551 School Statement
18-555 Financial Information Sheet