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.
Additionally, you may download the free Shana Informed filler to electronically complete Shana forms below. On opening your first Shana form, you will be asked to enter a registration key. Please enter 32064015014070671 (you only need to enter this once).
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 | |
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01-110 | Protective Payee Report | ||
01-110A | Protective Payee Periodic Social Services Report | ||
01-110C | Protective Payee Report Continuation | ||
01-205 | Basic Food Workfare Activity Report | ||
01-210 | Transmittal of Client Funds from the Protective Payee | ||
01-212 | ALTSA Nurse Delegation Referral and Communication Case / Resource Manager's Request | ||
02-516 | Adult Family Home Resident Personal Belongings Inventory (Residential Care Services) | ||
02-528 | Fair Hearing Withdrawal |
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02-556 | Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration) | ||
02-573 | Background check Identification Verification (Office of Deaf and Hard of Hearing) | ||
02-586 | Temporary Employment Hours Tracking Log | ||
02-589 | Companion Home Outside Employment Notification and Review (Developmental Disabilities Administration) | ||
02-592 | Application for Approval of Interpreter Continuing Education Activity | ||
02-611 | Statement of Understanding: Mid-Certification Review |
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02-632 | Residential Provider's Report of Weapon Ownership in Residential Setting | ||
02-634 | Additional Information Needed for ILP TANF | ||
02-690 | Student Evaluation Summary Report | ||
02-691 | Student Class Evaluation | ||
02-692 | Community Instructor Class List Tracking Log | ||
03-076 | Employee Personal Property Damage/Loss Claim | ||
03-077 | Release of All Claims | ||
03-133 | Safety Incident / Close Call Report | ||
03-374B | Agreement on Nondisclosure of Confidential Information - Non-Employee | ||
03-374D | ESA Non-Dislcosure of Confidential Information Agreement - Non Employee | ||
03-374E | Confidential Information, Fraud and Abuse | ||
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 without Acknowledgement |
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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 | ||
03-494 | Medication Administration Competency Assessment Tool | ||
04-220A | Indian Heritage Questionnaire (Developmental Disabilities Administration) | ||
04-442 | Nursing Home Credit Balance Report | ||
04-446 | Tell Us How We are Doing! (Division of Child Support) | ||
04-449 | Participants Feedback (Domestic Violence Intervention Treatment) | ||
04-449A | Survivors Feedback (Domestic Violence Intervention Treatment) | ||
05-010 | Rule Exception Request | ||
05-013 | Request for Hearing |
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05-246 | Notice of Action Exception to Rule (Excluding AFH) | ||
05-249 | Adult Residential Care Services Notice of a Change | ||
05-251 | Rule Change Comments (Residential Care Services) | ||
05-252 | Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation) | ||
05-254 | Federal Subminimum Wage Certificate Holder | ||
05-255 | Medicaid Transformation Demonstration 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) | ||
05-263 | Long Term Care Survey Process (LTCSP) Team Member Skill Building Tool | ||
05-263a | Long Term Care Survey Process (LTCSP) Team Coordinator Skill Building Tool | ||
06-123 | Nursing Assistant Training and Testing Reimbursement | ||
06-124 | Cost of Care Adjustment Request (Developmental Disabilities) | ||
06-125 | Residential Allowance Request / Insufficient Income and Housemate Allowance (Developmental Disabilities Administration) | ||
06-125A | Residential Allowance Request / Start Up Costs (Developmental Disabilities Administration) | ||
06-125B | Residential Allowance Request / Damage and Major Expenses (Developmental Disabilities Administration) | ||
06-159 | Psychologist and Sex Offender Treatment Provider Invoice | ||
06-162 | Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral | ||
06-165 | Extended Foster Care Denial Letter (Children's Administration) | ||
06-168 | AFH Change in Licensed Bed Capacity - Increase (Adult Family Home) (Residential Care Services) | ||
06-169 | AFH Change in Licensed Bed Capacity - Decrease (Adult Family Home) (Residential Care Services) | ||
06-171 | Funding and Expenditure Data (Tribal) | ||
06-172 | Domestic Violence Prevention Account | ||
06-173 | Medical Evidence Reimbursement | ||
06-174 | Enhanced Rate Proposal | ||
06-175 | Individual Provider (IP) Travel Time Request | ||
06-176 | ALF Change in Licensed Resident Bed Capacity or Use of Rooms | ||
06-177 | Residential Training Roster / Reimbursement (Developmental Disabilities Administration) | ||
06-180 | Nursing Services Activity Report for Home and Community Services (HCS) | ||
06-181 | Nursing Services Activity Report for AAAs | ||
06-182 | Public Records Customer Experience Survey | ||
07-042B | Self-Employment Income Report |
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07-081 | Participation Reimbursement | ||
07-097 | Individual Provider Planned Action Notice Training / Certification (Home and Community Services) | ||
07-098 | Self Employment Monthly Sales and Expense Worksheet |
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07-103 | Participant Reimbursement | ||
07-103A | Participant Reimbursement with Interpreter Declaration | ||
07-104 | Financial Communication to Social Services | ||
07-107 | Exception to Rule and Notice Guardianship Fees and Related Costs (Aging and Long-Term Support Administration and Developmental Disabilities Administration) | ||
09-004C | Voluntary Placement Agreement for Child or Youth with Developmental Disabilities | ||
09-013 | Vendor Affidavit of Lost, Stolen, or Destroyed Warrant | ||
09-052 | Affidavit of Forged Endorsement | ||
09-280B | Petition for Modification - Administrative Order |
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09-415 | Authorization for Expenditure (Non-Employee) | ||
09-508 | Waiver of Statute of Limitations |
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09-520 | Request for Conference Board |
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09-653 | Background Check Authorization |
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09-693 | Declaration of Lawful Custody |
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09-728 | Washington State Addendum to Box 2 of Part B - Plan Administrator Response | ||
09-741 | Child Support Order Review Request |
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09-762A | Petition for Court Validation of Voluntary Consent to Foster Care Placement of An Indian Child (Indian Child with Disabilities) (Developmental Disabilities Administration) | ||
09-809 | WorkFirst Word Experience (WEX) Referral | ||
09-810 | WorkFirst Word Experience (WEX) Agreement | ||
09-876 | Permanency Planning Findings and Order (Child With a Developmental Disability) | ||
09-877 | Notice of Hearing Re: Out-of-Home Placement (Child with a Developmental Disability) | ||
09-878 | Order Approving Continued Out-of-Home Care (Child With a Developmental Disability) | ||
09-892 | Petition for Review of Continued Out-of-Home Care (Child with Disabilities) (Developmental Disabilities Administration) | ||
09-893 | Periodic Review of Individual Service Plan (DDA) | ||
09-989 | Confidentiality Statement - Tribal Employee | ||
09-995 | Companion Home Evaluation and Review (Developmental Disabilities Administration) | ||
10-104B | Service Verification / Attendance Record For Alternative Living Providers (Developmental Disabilities Administration) | ||
10-210 | Staff Statement of Qualifications | ||
10-217 | Nurse Delegation: Nursing Assistant Credentials and Training | ||
10-231 | Adult Family Home (AFH) Placement Checklist (DDA) | ||
10-232 | Provider Referral Letter For Residential Services (Developmental Disabilities Administration) | ||
10-232A | AFH / ARC Provider Referral Letter | ||
10-234 | Individual with Challenging Support Issues (DDA) | ||
10-234A | Individual with Complex Behaviors (Aging and Long-Term Support Administration) | ||
10-237 | Nursing Home Transfer or Discharge Notice (Residential Care Services) | ||
10-238 | Request for an Administrative Hearing (Residential Care Services) | ||
10-244 | Shared Parenting Plan (Developmental Disabilities) | ||
10-246 | Permanency Plan | ||
10-255 | Public Health Nurse (PHN) Summary and Recommendations | ||
10-258 | Individual with Community Protection Issues (DDA) | ||
10-268 | Pre-Placement Agreement (Developmental Disabilities Administration) | ||
10-269 | Alternative Living Services Plan and Provider Progress Report (Developmental Disabilities Administration) | ||
10-269A | Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration) | ||
10-270 | Assisted Living Facility Admission Agreement(s) Attestation | ||
10-272 | Cross-System Crisis Plan (DDA) | ||
10-276 | WTRS Consumer Response (Office of Deaf and Hard of Hearing) | ||
10-277 | Request for Children's Residential Services | ||
10-301 | Notification of Eligibility Review (Developmental Disabilities Administration) |
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10-326 | Staffed Residential Rate Proposal (Developmental Disabilities Administration) | ||
10-328 | Residential Site Approval Request | ||
10-329 | Informed Consent for ICAP | ||
10-330 | Request For Legal Advice | ||
10-331 | DDA Mortality Review Provider Report (Developmental Disabilities Administration) | ||
10-334 | Monitoring of Side Effects Scale (MOSES) (DDA) | ||
10-337 | Important Information for SSP Recipients and Their Payees (DDA) | ||
10-339 | Nursing Care Consultant (NCC) Assessment (DDA) | ||
10-348 | Community Protection Program Information Checklist and Risk Assessment Consent (Developmental Disabilities Administration) | ||
10-349 | Comprehensive Regional Review Tool | ||
10-351 | Disclosure of Services Required by RCW 18.20.300 | ||
10-353 | Documentation Request for Medical or Disability Condition | ||
10-359 | Assisted Living Facility Pre Inspection Preparation - Attachment A | ||
10-360 | Boarding Home Request for Documentation - Assisted Living Facility Request For Documentation - Attachment B | ||
10-361 | Assisted Living Facility Resident List - Attachment C | ||
10-362 | Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D | ||
10-363 | Assisted Living Facility Resident Group Meeting - Attachment E | ||
10-365 | Assisted Living Facility Resident Interview - Attachment G | ||
10-366 | Assisted Living Facility Other Contact Interview - Attachment H | ||
10-367 | Assisted Living Facility Environmental Observations - Attachment I | ||
10-368 | Assisted Living Facility Resident Record Review - Attachment J | ||
10-369 | Assisted Living Facility Staff Sample / Record Review - Attachment K | ||
10-370 | Assisted Living Facility Notes / Worksheet - Attachment L | ||
10-371 | Assisted Living Facility Exit Preparation Worksheet - Attachment M | ||
10-372 | Assisted Living Facility Contract Requirements - Attachment N | ||
10-373 | Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O | ||
10-377 | Notification of Age Four (4) Eligibility Expiration- |
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10-378 | Notification of Age Ten (10) Eligibility Expiration |
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10-382 | Naturalization Services Pre-Screening | ||
10-389 | Room List For Assisted Living Facilities (ALF) | ||
10-389A | Additional Room List For Assisted Living Facilities (ALF) | ||
10-393 | Cost Estimate Worksheet for Hearing Aids and Services | ||
10-396 | SSI Letter (DDA) | ||
10-400 | Information Request Letter |
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10-403 | Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult | ||
10-410 | Adult Family Home License Application | ||
10-411 | Consumer Response: Do Not Hang Up Complaint | ||
10-412 | Adult Family Home License Relinquishment Letter | ||
10-413 | Application For Contract For Currently Licensed Boarding Home | ||
10-417 | Adult Family Home Caregiver Experience Attestation (CEA) | ||
10-422 | Adult Family Home (AFH) Quality Improvement Initial Visit | ||
10-423 | Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services | ||
10-424 | Voluntary Participation Statement (Developmental Disability Administration) | ||
10-427 | School District Communication | ||
10-437 | Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility | ||
10-438 | Long-Term Care Partnership (LTCP) Asset Designation | ||
10-442 | Goal Setting and Action Planning Worksheet | ||
10-448 | Nurse Delegation Contract Monitoring Chart Audit | ||
10-467 | ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services) | ||
10-468 | HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
10-471 | Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration) | ||
10-472 | Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration) | ||
10-481 | Health Action Plan (HAP) | ||
10-486 | Assisted Living Facility Food Service Observations - Attachment P | ||
10-487 | Assisted Living Facility Medication Pass Worksheet - Attachment Q | ||
10-488 | Extended Foster Care Program Consent | ||
10-489 | Confidential Health Information Consent Agreement | ||
10-501 | Referral to DSHS for Basic Food Employment and Training (BFET) | ||
10-503 | Limitation Extension Evaluation | ||
10-504 | Limitation Extension Request for Clients Under Age 21 | ||
10-505 | Limitation Extension Task Explanation | ||
10-506 | Limitation Extension Request Checklist | ||
10-508 | Adult Family Home Disclosure of Services Required by RCW 70.128.280 | ||
10-509 | Pediatric Symptoms Checklist (PSC-17) | ||
10-535 | Enhanced Services Facility Application | ||
10-570 | Intake and Referral | ||
10-571 | Overnight Planned Respite Services Individualized Agreement | ||
10-572 | Respite Application for Overnight Planned Respite (OPRS), Emergent and/or Planned Short-Term Stay Services at an RHC | ||
10-573 | Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination | ||
10-574 | Roads to Community Living (RCL) Person Centered Transition Planning | ||
10-577 | Assisted Living Facility Other Contact Information - Attachment R | ||
10-580 | Adult Day Services Referral | ||
10-582 | Notification of Age 19 Eligibility Review (Developmental Disabilities Administration) |
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10-583 | DDA PASRR Cover Sheet | ||
10-584 | Data Summary Report and Recommendations (Developmental Disabilities Administration) | ||
10-585 | Adult Family Home Information Changes | ||
10-589 | Comprehensive Functional Assessment of Recreation | ||
10-590 | Comprehensive Functional Assessment of Physical Therapy | ||
10-591 | Assisted Living Facility License Application | ||
10-592 | Comprehensive Functional Assessment of Direct Care Independent Living Skills | ||
10-593 | Restraint / Support Evaluation | ||
10-593A | Restraint / Support Evaluation Continuation | ||
10-594 | Comprehensive Functional Assessment of Communication | ||
10-595 | Comprehensive Functional Assessment of Occupational Therapy | ||
10-596 | Comprehensive Functional Assessment of Adult Training Programs | ||
10-601 | Assisted Living Facility Information Changes | ||
10-602 | Enhanced Services Facility Information Changes | ||
10-603 | Nursing Home Information Changes | ||
10-604 | Supported Living Information Changes (Residential Care Services) | ||
10-605 | ICF / IID Information Changes (Residential Care Services) | ||
10-611 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services) | ||
10-612 | Certified Community Residential Services and Supports (CCRSS) Pre-Certification Evaluation Preparation (Residential Care Services) | ||
10-613 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Observation(Residential Care Services) | ||
10-614 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services) | ||
10-615 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Family / Representative / Collateral Contact Interview (Residential Care Services) | ||
10-616 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Interview (Residential Care Services) | ||
10-617 | Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services) | ||
10-618 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services) | ||
10-619 | Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (Residential Care Services) | ||
10-620 | Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services) | ||
10-621 | Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services) | ||
10-622 | Certified Community Residential Services and Supports (CCRSS) Group Training Home Food Service Observations and Interviews (Residential Care Services) | ||
10-623 | DDA PASRR Significant Change Invalidation (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review) | ||
10-625 | State Task Checklist (Aging and Long-Term Support Administration) | ||
10-626 | Staffing Pattern (Aging and Long-Term Support Administration) | ||
10-627 | Liability Insurance Review (Aging and Long-Term Support Administration) | ||
10-628 | Trust Fund Review (Aging and Long-Term Support Administration) | ||
10-629 | Pet Record Review (Aging and Long-Term Support Administration) | ||
10-630 | Paid Feeding Assistant Program Review (Aging and Long-Term Support Administration) | ||
10-631 | Staff Qualification and Background Review (Aging and Long-Term Support Administration) | ||
10-632 | TB Testing Review for Staff (Aging and Long-Term Support Administration) | ||
10-633 | TB Testing Review for Resident (Aging and Long-Term Support Administration) | ||
10-634 | Medication Assistant Endorsement (Aging and Long-Term Support Administration) | ||
10-635 | Residential Transition Exchange of Information (Developmental Disabilities Administration) | ||
10-636 | Meaningful Day Monthly Calendar | ||
10-637 | Meaningful Activity Plan (MAP) Discovery | ||
10-638 | AFH Meaningful Day - Monthly Activities and Challenging Behavior Log | ||
10-639 | Overnight Planned Respite Services (OPRS) Certification Evaluation (Developmental Disabilities Administration) | ||
10-640 | Emphasis on Hands-On Skills Practice: Planning Attestation (Home and Community Services) | ||
10-641 | Community Instructor Qualification Tool (Home and Community Services) | ||
10-642 | Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services) | ||
11-019 | Vocational Information (Division of Vocational Rehabilitation) | ||
11-022 | Application for Vocational Rehabilitation Services | ||
11-030 | Service Delivery Outcome Report (Community Rehabilitation Program - CRP) | ||
11-034B | Basic Food Eligibility Requirements: What You Need to Know |
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11-045 | Work Experience (WEX) Referral (Food Stamp Employment and Training) | ||
11-046 | Work Experience (WEX) Agreement (Food Stamp Employment and Training) | ||
11-055 | Acknowledgement of My Responsibilities As The Employer of My Individual Providers |
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11-058 | Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation) | ||
11-066 | Assistive Communication Technology Request (Office of Deaf and Hard of Hearing) | ||
11-067 | Monthly Budget Worksheet (Division of Vocational Rehabilitation) | ||
11-068 | DVR Internship Application (Division of Vocational Rehabilitation) | ||
11-069 | DVR Internship Agreement (Division of Vocational Rehabilitation) | ||
11-070 | DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation) | ||
11-071 | DVR Employer Expense Worksheet (Division of Vocational Rehabilitation) | ||
11-072 | DVR Internship Evaluation (Division of Vocational Rehabilitation) | ||
11-078 | Centers for Independent Living (CILs), Title VII, Part B Two-Year Plan (Division of Vocational Rehabilitation) | ||
11-079 | Centers for Independent Living (CILs) Title VII, Part B, Contract Annual Report | ||
11-080 | Centers for Independent Living (CILs) Title VII, Part B Monthly Report | ||
11-084 | Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation) | ||
11-088 | DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet | ||
11-093 | Outreach Attendance (Office of the Deaf and Hard of Hearing) | ||
11-097 | Service Delivery Outcome Report (Independent Living Services - IL) | ||
11-098 | Vocational Assessment Worksheet | ||
11-100 | Community Rehabilitation Program (CRP) Generic Update Report | ||
11-106 | Pre-ETS (Pre-Employment Transition Services) Self-Advocacy Training (Division of Vocational Rehabilitation) | ||
11-107 | Pre-ETS (Pre-Employment Transition Services) Peer Mentoring (Division of Vocational Rehabilitation) | ||
11-110 | Pre-ETS (Pre-Employment Transition Services) Informational Interview (Division of Vocational Rehabilitation) | ||
11-111 | Pre-ETS (Pre-Employment Transition Services) Job Exploration (Division of Vocational Rehabilitation) | ||
11-112 | Pre-ETS (Pre-Employment Transition Services) Job Shadow (Division of Vocational Rehabilitation) | ||
11-113 | Pre-ETS (Pre-Employment Transition Services) Social Skills (Division of Vocational Rehabilitation) | ||
11-114 | Referral Contact Sheet | ||
11-115 | Workplace Readiness Report | ||
11-116 | Work-Based Learning Report | ||
11-117 | Student Summary Report | ||
11-118 | Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation) | ||
11-119 | Informational Interview Worksheet (Division of Vocational Rehabilitation) | ||
11-121 | Enhanced Case Management Referral Consideration (Developmental Disabilities Administration) | ||
11-123 | Service Delivery Outcome Plan: WBL - Experience A | ||
11-124 | Service Delivery Outcome Plan: WBL - Experience B | ||
11-125 | Service Delivery Outcome Plan: WBL - Experience C | ||
11-132 | 90 Day Review (Division of Vocational Rehabilitation) | ||
11-133 | Jobs and Training Inventory (Division of Vocational Rehabilitation) | ||
11-134 | Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation) | ||
11-142 | Service Delivery Outcome Plan: Pre-ETS IL Skills Training | ||
11-146 | Supported Employment Referral (Economic Services Administration) |
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11-149 | Division of Vocational Rehabilitation (DVR) Customer Job Seeker Accommodation Worksheet | ||
12-006 | Basis of Issuance Tables and Maximum Allowable Monthly Gross and Net Income Standards for the Washington Basic Food Program | ||
12-195 | Disqualification Consent Agreement | ||
12-206 | Application for Disaster Food Benefits | ||
12-207 | Application for Disaster Cash Assistance | ||
12-209 | Client Fraud Report | ||
12-210 | Medicaid Provider Fraud Report | ||
13-021 | Physical Evaluation | ||
13-585A | Range of Joint Motion Evaluation Chart | ||
13-645 | Adult Family Home Injuries and Accidents Log | ||
13-678 Page 1 | Nurse Delegation: Consent for Delegation Process | ||
13-678 Page 2 | Nurse Delegation: Instructions for Nursing Task | ||
13-678A | Nurse Delegation: PRN Medication | ||
13-678B | Nurse Delegation: Assumption of Delegation | ||
13-680 | Nurse Delegation: Rescinding Delegation | ||
13-681 | Nurse Delegation: Change in Medical Orders | ||
13-692A | Assisted Living Facility (ALF) Dementia Screening Tool | ||
13-712 | Behavioral Health Personal Care Request for BHO / MCO Funding (Aging and Long-Term Support Administration) | ||
13-713 | Fast Track Service Agreement |
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13-734 | Documentation of First Use of Medicaid Benefits (DDA) | ||
13-738 | DDA / CA Request to Cost Share | ||
13-776 | HCS / AAA Nursing Services Referral (Home and Community Services) | ||
13-780 | Nursing Services Basic Skin Assessment (Home and Community Services) | ||
13-783 | Pressure Injury Assessment and Documentation (Home and Community Services) | ||
13-784 | Nursing Services Assessment | ||
13-830 | Admissions Review Team Checklist for Admission to an ICF / IID or SONF at a Residential Habilitation Center (RHC) (Developmental Disabilities Administration) | ||
13-851 | Psychiatric Referral Summary | ||
13-851A | Psychoactive Medication Treatment Plan | ||
13-851C | Psychoactive Medication Treatment Plan Annual Continuation of Medication | ||
13-865 | Psychological / Psychiatric Evaluation | ||
13-893 | Nurse Delegation: Request For Additional Units | ||
13-899 | Review of Medical Evidence | ||
13-903 | DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration) | ||
13-905 | Autistic Disorder Confirmation (Developmental Disabilities Administration) | ||
13-906 | Therapy Assessment Bed Rails or Side Rails (Home and Community Services) | ||
13-911 | DDA Nursing Service Referral (Developmental Disabilities Administration) | ||
13-915 | Information for Respite Care Service Providers: Addendum to TCARE Assessment | ||
13-917 | CCSS Medical / Dental Services Authorization (Community Crisis Stabilization Services) (Developmental Disabilities Administration) | ||
14-001 | Application for Cash or Food Assistance | ||
14-012 | Consent |
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14-050 | Statement of Health, Education, and Employment | ||
14-057 | Child Support Referral |
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14-057B | Noncustodial Parent Child Support Enforcement Application | ||
14-057D | Child Support Referral Continuation | ||
14-068 | Financial Statement (Division of Vocational Rehabilitation) | ||
14-076 | Change of Circumstances | ||
14-078 | Eligibility Review |
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14-084 | Social Service Referral | ||
14-105 | Interview Appointment for Applicant (Community Services Division) |
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14-113 | Your Cash and Food Assistance Rights and Responsibilities |
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14-144A | Medical Disability Decision | ||
14-151 | Request for DDA Eligibility Determination |
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14-155 | Senior Citizens Service Application | ||
14-162 | Veteran's Referral | ||
14-222 | Statement of Collateral Information |
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14-222 SUMMARY | Statement of Collateral Information Summary | ||
14-223 | Statement from School | ||
14-224 | Statement from Landlord/Manager |
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14-225 | Acknowledgement of Services |
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14-238 | Client Income Report | ||
14-252 | Employment Verification |
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14-264 | Application for Telecommunications Equipment | ||
14-299 | Adult Assessment Referral (Economic Services Administration) | ||
14-300 | Level One Pre-Admission Screening and Resident Review (PASRR) | ||
14-310 | Client Status Change Report | ||
14-332 | Disability Assessment | ||
14-341 | Application to Convert Payment Services Only (PSO) Case to Full Collection Services | ||
14-349 | Protective Payee Assessment |
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14-381 | WorkFirst Individual Responsibility Plan |
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14-401 | Notification of Address Disclosure Request - Part 1 | ||
14-401A | Notification of Address Disclosure Request - Part 2 | ||
14-402 | Notice to Parents (WorkFirst) | ||
14-416 | Eligibility Review for Long Term Services and Supports |
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14-426 | Protective Payee Payment Plan, Case Assignment, and Closure Notice |
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14-427 | Teen Parent Living Assessment | ||
14-431 | Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration) | ||
14-431A | Community Crisis Stabilization Services (CCSS) Medical / Dental Services Authorization (Developmental Disabilities Administration) | ||
14-432 | Direct Deposit Enrollment | ||
14-436 | Statement of Adult Acting in Loco Parentis (As a Parent) | ||
14-438 | Stop Work |
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14-439 | WASHCAP Application | ||
14-440 | Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing) | ||
14-443 | Financial / Social Services Communication | ||
14-449 | Unmet Need Breakdown | ||
14-453 | Protective Payee Decision | ||
14-454 | Estate Recovery: Repaying the State for Medical and Long Term Services and Supports |
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14-459 | Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration) |
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14-460 | Notice of Insufficient Information (Developmental Disabilities Administration) |
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14-462 | Epilepsy Verification Request (Developmental Disabilities Administration) | ||
14-463 | Waiver Transportation Record (DDA) | ||
14-467 | Mid-Certification Review | ||
14-473 | Inventory for Client and Agency Planning (ICAP) Letter | ||
14-475 | Appointment Letter for Division of Child Support (DCS) Good Cause Determination |
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14-478 | Treatment Verification Request |
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14-484 | Nurse Delegation: Nursing Visit | ||
14-489 | SSIF Introduction Letter |
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14-491 | NSA Representative Checklist forDDA Review | ||
14-492 | Assessment Meeting Wrap-up | ||
14-493 | Requirement to Identify a Representative (Developmental Disabilities Administration) | ||
14-495 | Naturalization Letter |
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14-501 | Community Resource Declaration | ||
14-502 | SSI Hearing Denial | ||
14-503 | Interim Assistance Reimbursement Agreement Cover |
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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 |
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14-521 | Your Rights (Home and Community Services) |
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14-525 | Incapacity Review for Medical Care Services |
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14-526 | Chemical Dependency Treatment Verification Request | ||
14-527 | Substance Use Disorder Requirements (HEN Referral Program) | ||
14-528 | Chemical Dependency NonCooperation | ||
14-529 | Substance Use Disorder Requirements (ABD / PWA) | ||
14-530 | Disability Review |
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14-532 | Authorized Representative |
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14-534 | SDCP Eligibility Checklist (Home and Community Services) | ||
14-535 | Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration) | ||
14-538 | Pre-Admission Screening and Resident Review (PASRR) Addendum | ||
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) | ||
14-547 | Continuing Care Retirement Community (CCRC) Registration Application | ||
15-031 | Nursing Facility Notice of Action | ||
15-184 | Volunteer Chore Service Referral | ||
15-186 | DSHS Volunteer Application | ||
15-215 | AFH Quality Improvement Visit Assessment | ||
15-252 | DRW Access Request Checklist | ||
15-274 | Assistance Available Schedule (DDA) | ||
15-282A | Request for Enrollment in Developmental Disabilities Administration (DDA) Home and Community Based Services (HCBS) Waiver or Request to Change from One DDA HCBS Waiver to Another | ||
15-290 | Notification of Annual Assessment Review and Person Centered Services Planning Meeting | ||
15-291 | Person Centered Service Planning and Annual Assessment Meeting | ||
15-295 | Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration) | ||
15-304 | HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration) | ||
15-314 | Client Necessary Supplemental Accommodation Representative Requirement Checklist | ||
15-318 | DDA Crisis Diversion Bed Referral and Intake Information | ||
15-331 | Annual Assessment Checklist (Developmental Disability Administration) | ||
15-342 | Notice of Exception to Rule Decision | ||
15-344 | Private Duty Nursing Logs and Skilled Nursing Tasks Log | ||
15-356 | DDA Community Protection Program Chaperone Agreement | ||
15-358 | Client Referral Summary (Developmental Disabilities Administration) | ||
15-360 | Residential Services Capacity Profile | ||
15-365 | Community Protection Treatment Worksheet Quarterly Review | ||
15-366 | Change of Address | ||
15-376 | Skin Observation Protocols | ||
15-379 | Staff Add-on Request for Client Specific Need (Developmental Disabilities Administration)) | ||
15-380 | Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration) | ||
15-381 | Respite Assessment Worksheet | ||
15-382 | Positive Behavior Support Plan (PBSP) | ||
15-383 | Functional Behavioral Assessment (FA) | ||
15-384 | Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA) | ||
15-385 | Provider Consent For Use of Restrictive Procedures Requiring an ETP | ||
15-387 | Children’s Respite Application | ||
15-388 | Alternative Living Review and Evaluation | ||
15-389 | Certified Community Residential Services and Support Initial Application | ||
15-398 | Medically Intensive Children's Program (MICP) Application | ||
15-419 | Refusal of Services Statement | ||
15-420 | Request For ICF / IID or SONF Admission | ||
15-422 | No Paid Services Group | ||
15-424 | Staffed Residential Cost of Care Adjustment Request | ||
15-435 | Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration | ||
15-436 | Request for Adult Family Home Application Fee Waiver | ||
15-437 | RCS Staff Orientation Checklist | ||
15-438 | Inspection (Assisted Living Facility) | ||
15-439 | Follow-up / Monitoring Inspection (Assisted Living Facility) | ||
15-440 | Complaint Investigation (Assisted Living Facility) | ||
15-441 | Team Coordinator (Assisted Living Facility) | ||
15-444 | Re-Inspection | ||
15-445 | Follow-up / Monitoring Inspection | ||
15-446 | Complaint Investigation | ||
15-447 | Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services) | ||
15-449 | Adult Family Home Disclosure of Charges Required by RCW 70.128.280 | ||
15-456 | RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
15-458 | Adult Family Home Notice of Transfer or Change | ||
15-473 | Notification of Age 18 Eligibility Expiration | ||
15-474 | Notification of Age 20 Eligibility Expiration | ||
15-481 | CCRSS Complaint Investigation | ||
15-487 | ICF/IID Complaint Investigation (Residential Care Services) | ||
15-492 | Medicaid Transformation Demonstration Service Notice | ||
15-493 | PASRR Client Referral | ||
15-494 | Guardian / Family Response to Individual Habilitation Plan (IHP) Notification (Developmental Disabilities Administration) | ||
15-495 | Individual Habilitation Plan (IHP) (Developmental Disabilities Administration) | ||
15-496 | Individual Habilitation Plan (IHP) Revision (Developmental Disabilities Administration) | ||
15-508 | Consent and Service Agreement (Developmental Disabilities Administration) | ||
15-509 | Provider Progress Report of Community Guide and Engagement Services (Developmental Disabilities Administration)) | ||
15-512 | Companion Home and Alternative Living Services Incident Report (Developmental Disabilities Administration) | ||
15-514 | Companion Home (CH) Client Individual Financial Plan (IFP) (Developmental Disabilities Administration) | ||
15-515 | CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration) | ||
15-516 | Companion Home Quarterly Report (Developmental Disabilities Administration) | ||
15-517 | Application for Transition from Group Home to Group Training Home | ||
15-547 | Continuing Education Event Approval Application (Aging and Long-Term Support Administration) | ||
15-548 | Adult Family Home Administrator Training Instructor Application (Home and Community Services) | ||
15-549 | Community Instructor Application: DSHS Adult Education (Home and Community Services) | ||
15-550 | Community Instructor Application (Home and Community Services) | ||
15-551 | Community Instructor Training Program Application and Updates (Home and Community Services) | ||
15-552 | Curriculum Approval Application (Home and Community Services) | ||
15-553 | Long-Term Care Worker Basic Training Enhancement Instructions and Application (Home and Community Services) | ||
15-554 | Facility Instructor Application (Home and Community Services) | ||
15-555 | Facility Training Program Application and Updates (Home and Community Services) | ||
15-556 | Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration) | ||
15-558 | Adult Family Home (AFH) Resident Significant Change Assessment Request | ||
15-559 | Adult Family Home Referral Request (Developmental Disabilities Administration) | ||
15-560 | Room Requirements Checklist (Home and Community Services) | ||
16-072 | NonAssistance Support Enforcement Information (Division of Child Support) | ||
16-107 | Noncustodial Parent's Rights and Responsibilities |
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16-172 | Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration |
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16-182 | Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration) | ||
16-191 | SOLA Vehicle Trip Log (Developmental Disabilities Administration) | ||
16-193 | Nurse Aide Registry Inquiry (ADSA) | ||
16-194 | DDA Specialty Training Sign-Up Sheet | ||
16-195 | Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative | ||
16-197 | Assisted Living Facility Policies and Procedures Attestation | ||
16-198 | Individual Provider Notification: Stop Work Notice | ||
16-199 | New Case/Resource Manager Technology Training Checklist | ||
16-200 | Memo to Provider for Behavior Support, Counseling, and Consultation Services | ||
16-202 | 5-Day Investigation Report | ||
16-202A | Plan of Correction (5-Day Investigation) | ||
16-203 | SIS-A Rating Key (Developmental Disabilities Administration) | ||
16-205 | Personal Emergency Plan Information | ||
16-213 | Verification of Legal Status | ||
16-218 | Intake Cover Letter to Tribes | ||
16-230 | Children's Residential Services | ||
16-234 | Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF) | ||
16-234A | Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC)) | ||
16-235 | Photo Release | ||
16-237 | DDA GovDelivery Communication Request (Developmental Disabilities Administration) | ||
16-237A | ALTSA GovDelivery Communication Request (Aging and Long-Term Support Administration) | ||
16-242 | Ask DSHS | ||
16-243 | Community Services Office (CSO) Compliments and Concerns (Economic Services Administration) | ||
17-011 | Forms and Publications Request | ||
17-041 | Request for Records | ||
17-063 | Authorization |
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17-116 | AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion | ||
17-123 | Spoken Language Interpreter Service Appointment Record | ||
17-123A | Request for Sign Language Interpreter | ||
17-155 | Sign Language Interpreter Registration | ||
17-180 | Personal Information Release (Economic Services Administration) | ||
17-194 | Request for Mental Health Service Information | ||
17-208A | PRISM Access Request for Multiple Organizations | ||
17-211 | Authorization for SSI Facilitation Records (Economic Services Administration) | ||
17-226 | AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration) | ||
17-227 | DSHS / HCA Systems Access Request | ||
17-229 | Pre-Admission Screening and Resident Review (PASRR) Records Request | ||
17-230 | Non-Emergency Medical Transportation (NEMT) for PASRR Program Request | ||
17-231 | Mental Incapacity Evaluation (MIE) Contractor Travel Plan | ||
17-238 | ODHH Approved Sign Language Interpreter Complaints | ||
17-242 | Residential Habilitation Center (RHC) Informed Consent (Developmental Disabilities Administration) | ||
17-253 | DSHS Background Check System (BCS) Access Request | ||
17-257 | Companion Home Client Budget Worksheet (Developmental Disabilities Administration) | ||
17-258 | Companion Home Client Cash Ledger (Developmental Disabilities Administration) | ||
17-259 | Companion Home Client Inventory Record | ||
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) | ||
18-078 | Application for Nonassistance Support Enforcement Services | ||
18-097 | Statement of Resources and Expenses |
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18-176 | Address Release Information Letter | ||
18-176A | Address Release Information Letter | ||
18-235 | Initial payment (Interim Assistance Reimbursement Authorization) |
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18-334 | How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs |
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18-398 | Client Overpayment Notice | ||
18-398A | Vendor 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) |
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18-463 | New Hire Reporting Methods and Instructions | ||
18-464 | Introduction to New Hire Reporting | ||
18-483 | Employer Payment Identification Instructions | ||
18-484 | Automatic Payment Authorization and Electronic Funds Transfer Information |
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18-544 | Transmittal of Resident Personal Funds | ||
18-551 | School Statement |
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18-555 | Financial Information Sheet | ||
18-607 | Child Care Verification |
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18-627 | SSP Client Overpayment Notice (State Supplementary Program) | ||
18-681 | Request for Collection of Uninsured Health Care Expenses | ||
18-682 | Detail Sheet – 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) | ||
21-059 | Children's Staffed Residential Quality Assurance Assessment | ||
21-060 | Children’s State Operated Living Alternative (SOLA) Quality Assurance Assessment | ||
21-061 | Companion Home Monthly Emergency Evacuation Practice and Water Temperature Record (Developmental Disabilities Administration) | ||
23-034 | Alternative Living Financial Report | ||
23-045 | Community Services Division (CSD) Financial Confidence Wheel (Economic Services Division) | ||
27-043 | Contractor Intake | ||
27-044A | Contractor Information Update (for existing DSHS contractors) | ||
27-051 | DSHS / Union Contract Decision Process | ||
27-053 | Paternity Information | ||
27-057 | Voluntary Placement Services Provider Referral Letter (DDA) | ||
27-059 | Fingerprint Appointment | ||
27-063 | Voluntary Placement Services For Youth (Age 18-21) | ||
27-076 | Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult | ||
27-081 | Employment and Day Program Services Providers: Mandatory Reporting of Abuse, Improper Use of Restraint, Neglect, Personal or Financial Exploitation, Abandonment of a Child or Vulnerable Adult (Developmental Disability Administration) | ||
27-089 | Fingerprint-Based Background Check Notice | ||
27-094 | Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration) | ||
27-096 | Permission to Share Documents for Reimbursement of Health Care Expenses | ||
27-109 | BCCU Applicant Affidavit | ||
27-110 | Applicant Request for a Copy of Background Check Information | ||
27-115 | Privacy Complaint | ||
27-122 | HCS / AAA / DDA Individual Provider Contractor Intake | ||
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 | ||
27-144 | CSD Disability Eligibility Review Contractor Self-Assessment Monitoring Tool | ||
27-147 | Housing Modification Property Release Agreement | ||
27-155 | Declaration on Commercial Purposes | ||
27-156 | Notice and Consent of Communication via Text | ||
27-168 | Authorization of Disclosure (Economic Services Administration) | ||
27-175 | DVR Additional Contractor Information (Division of Vocational Rehabilitation) | ||
27-176 | Release of Liability (Developmental Disabilities Administration) | ||
27-177 | Notice and Consent of Communication via Text | ||
27-178 | Adult Protective Services (APS) Administrative Hearing Request |