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 | |
|---|---|---|---|
| 03-374E | Nondisclosure of Confidential Information Agreement for Non-Employee (eJAS Access) | ||
| 03-387 | DSHS Notice of Privacy Practices for Client Medical Information |
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| 03-387A | DSHS Notice of Privacy Practices for Client Medical Information with Acknowledgement |
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| 03-387B | DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs |
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| 03-389A | Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790) | ||
| 03-391 | Report of Possible Client Assault | ||
| 03-490 | Employee / Contractor Awareness IRS Safeguard Training Certification | ||
| 04-449A | Survivors Feedback (Domestic Violence Intervention Treatment) | ||
| 05-013 | Request for Hearing |
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| 05-246 | Notice of Action Exception to Rule (Excluding AFH) | ||
| 05-248 | On-Site Review (Office of Refugee and Immigrant Assistance) | ||
| 05-249 | Adult Residential Care Services Notice of a Change | ||
| 05-252 | Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation) | ||
| 05-255 | Medicaid Transformation Project Notice of Action Exception to Rule | ||
| 05-256 | Notice of Action Exception to Rule for AFH Daily Rates | ||
| 05-258 | Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment | ||
| 05-259 | Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment) | ||
| 05-260 | Change of Address for an Existing DVIT Certification (Domestic Violence Intervention Treatment) | ||
| 05-261 | Add, Change, or Remove Direct Service Staff for a Certified DVIT Program (Domestic Violence Intervention Treatment) | ||
| 05-262 | Add or Remove a Service for an Existing DVIT Certification (Domestic Violence Intervention Treatment) | ||
| 06-124 | Cost of Care Adjustment (COCA) (Developmental Disabilities) | ||
| 06-162 | Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral | ||
| 06-176 | Assisted Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms | ||
| 06-184 | Adult Family Home (AFH) Capacity Increase Working Papers (Residential Care Services) | ||
| 06-186 | Financial Solvency Information (Aging and Long-Term Support Administration) |
