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
14-463 Waiver Transportation Record (DDA)
14-465 Sources for Eligibility Information (Developmental Disabilities Administration)
14-473 Inventory for Client and Agency Planning (ICAP) Letter
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
14-478 Aged, Blind, or Disabled (ABD) Program Medical Treatment Participation
14-491 NSA Representative Checklist forDDA Review
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center
14-515 Notice and Finding of Responsibility
14-517 DSHS Letter Requesting Non Work SSN
14-520 Your DSHS Cash or Food Assistance Benefits
14-525 Incapacity Review for Medical Care Services
14-526 ABD, PWA, and HEN Referral Substance Use Disorder Treatment Verification
14-527 Substance Use Disorder Requirements (HEN Referral Program)
14-529 Substance Use Disorder Requirements (ABD / PWA)
14-532 Authorized Representative
14-535 Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration)
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)
14-552 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