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
18-544 Transmittal of Resident Personal Funds
18-551 School Statement
18-555 Financial Information Sheet
18-681 Request for Collection of Uninsured Health Care Expenses
18-700 Direct Deposit Authorization
18-701 Request for Income Information for Purposes of Entering or Enforcing a Child Support Order
19-074 Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation)
20-273 Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program
20-330 Incident Report to DDA (Developmental Disabilities Administration)
20-332 Appropriate Level of Forensic Services (ALFS) Screening Tool
20-333 Outpatient Competency Restoration Program (OCRP) Transition Plan (Behavioral Health Administration)
20-334 Washington State Learning Center (LC) New Course Request (Division of Developmental Disabilities)
21-061 Companion Home Monthly Emergency Evacuation Practice and Water Temperature Record (Developmental Disabilities Administration)
27-043 New Contractor Intake
27-044A Contractor Information Update (for existing DSHS contractors)
27-053 Paternity Information
27-063 Out-of-Home Services Agreement for Youth (Age 18-21) (Developmental Disabilities Administration)
27-076 Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
27-094 Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration)
27-096 Permission to Share Documents for Reimbursement of Health Care Expenses
27-110 Applicant Request for a Copy of Background Check Information
27-123 Provider Owned Housing Memorandum of Understanding Renter Attestation
27-124 Provider Owned Housing Memorandum of Understanding Residential Provider Attestation
27-130 Authorization for Alternate EBT Cardholder
27-143 CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool