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Home / Cna Long Term Care Supplemental Statement Verification Form

Cna Long Term Care Supplemental Statement Verification Form

00-396 RCS Supported Living Infection Prevention Assessment Tool for COVID-19 00-398 Phase 1 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services) 00-399 Phase 2 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services) 00-410 Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control Assessment (IPC) Pathway (Residential Care Services) 00-411 Adult Family Home (AFH) Assisted Living Facility (ALF) Enhanced Services Facility (ESF) Community Program Infection Prevention and Control (IPC) Assessment Pathway (Residential Care Services) 00-412 RCS (AFH, ALF, and ESF) Infection Prevention and Control (IPC) Assessment Tool for COVID-19 (Residential Care Services) (Adult Family Home, Assisted Living Facility, and Enhanced Services Facility) 00-412A RCS (AFH, ALF, and ESF) Infection Prevention and Control (IPC) Assessment Notes for COVID-19 (Residential Care Services) (Adult Family Home, Assisted Living Facility, and Enhanced Services Facility) 00-413 Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Tool for COVID-19 (Residential Care Services) 00-413A Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Notes for COVID-19 (Residential Care Services) 01-110 Protective Payee Report 01-110A Protective Payee Periodic Social Services Report 01-110C Protective Payee Report Continuation 01-205 Able Bodied Adults Without Dependents (ABAWD) Activity Report 01-210 Transmittal of Client Funds from the Protective Payee 01-212 Nurse Delegation Referral and Communication 01-218 Community Inclusion Rate Adjustment for Staffed Residential Rate 02-516 Adult Family Home Resident Personal Belongings Inventory (Residential Care Services) 02-528 Fair Hearing Withdrawal 02-556 Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration) 02-566 Protected Health Information (PHI) Amendment 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 and Translator Continuing Education Activity 02-611 Statement of Understanding: Mid-Certification Review 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 02-709 Adult Family Home (AFH) Personnel Changes (Aging and Long-Term Support Administration) 02-714 DSHS Virtual Classroom Training Application (Home and Community Services) 02-714A DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services)
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02-716 Rapid Response Team 2 Request (Residential Care Services) (Aging and Long-Term Support Administration) 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 Nondisclosure of Confidential Information Agreement for Non-Employee (eJAS Access) 03-387 DSHS Notice of Privacy Practices for Client Medical Information 03-387A DSHS Notice of Privacy Practices for Client Medical Information without Acknowledgement 03-387B DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs 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 03-506 Character, Competence, and Suitability Assessment 03-509 DSHS Unpaid Intern / Volunteer Application 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) 04-452 DSHS Community Services Survey (Community Services Division, Economic Services Administration) 05-010 Rule Exception Request 05-013 Request for Hearing 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
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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) 05-267 Self-Assessment and Monitoring Tool (Home and Community Services) 05-268 Community Instructor Self-Assessment (Home and Community Services) 05-269 Community Instructor Self-Assessment for Contract Renewal and/or for Newly Established Contracts (Home and Community Services) 05-272 Case Manager Instructions Following a Hearing Decision 05-273 Private Duty Nursing (PDN) Pre-Contract Education Attestation (Home and Community Services) 05-274 Residential Referral Transition (Developmental Disabilities Administration) 06-123 Nursing Assistant Training and Testing Reimbursement 06-124 Cost of Care Adjustment (COCA) (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 (Developmental Disabilities Administration) 06-125C Residential Allowance Request - Shelter Expense (Developmental Disabilities Administration) 06-159 Psychologist and Sex Offender Treatment Provider Invoice 06-159A Specialized Evaluation and Treatment Provider Invoice 06-162 Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral 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 Assisted Living Facility (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 06-184 Adult Family Home (AFH) Capacity Increase Working Papers (Residential Care Services) 06-186 Financial Solvency Information (Aging and Long-Term Support Administration) 06-188 Adult Protective Services (APS) Investigations Fact Sheet (Aging and Long-Term Support Administration) 06-189 Notice of Suspension of Supported Living Services (Developmental Disabilities Administration) 07-042B Self-Employment Income Report 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 07-103 Basic Food Employment and Training (BFET) 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 09-415 Authorization for Expenditure (Non-Employee) 09-508 Waiver of Statute of Limitations 09-520 Request for Conference Board 09-653 Background Check Authorization 09-693 Declaration of Lawful Custody 09-728 Washington State Addendum to Box 2 of Part B - Plan Administrator Response 09-741 Child Support Order Review Request 09-989 Confidentiality Statement - Tribal Employee 09-995 Companion Home Certification Evaluation (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) Referral 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) 10-255 Public Health Nurse (PHN) Summary and Recommendations 10-258 Individual With Possible Community Protection Issues (Developmental Disabilities Administration) 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
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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 Out-of-Home Services (Developmental Disabilities Administration) 10-301 Notification of Eligibility Review (Developmental Disabilities Administration) 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 Condition and Residual Functional Capacity 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- 10-378 Notification of Age Ten (10) Eligibility Expiration 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 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 10-412 Adult Family Home License Relinquishment Letter 10-413 Application For Contract For Currently Licensed Assisted Living Facility 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 10-583 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) 10-643 PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration) 10-644 Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA) 10-645 Residential Certification Evaluation Client Interview (Developmental Disabilities Administration) 10-646 Residential Certification Evaluation Legal Representative Interview (Developmental Disabilities Administration) 10-647 Residential Certification Evaluation Staff Interview (Developmental Disabilities Administration) 10-648 Planned Action Notice PASRR Determination Supporting Information (Pre-Admission Screening and Resident Review) (Developmental Disabilities Administration) 10-649 Children's State Operated Living Alternatives (SOLA) Certification Evaluation (Developmental Disabilities Administration) 10-650 Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) 10-650A Adult Family Home (AFH) Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) 10-653 State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application 10-655 Initial Staff and Family Consultation Plan (Developmental Disabilities Administration) 10-656 Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration) 10-656 Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration) 10-657 Initial Specialized Habilitation Plan (Developmental Disabilities Administration) 10-658 Specialized Habilitation 90-Day (Quarterly) Report (Developmental Disabilities Administration) 10-659 Initial Community Engagement Plan (Developmental Disabilities Administration) 10-659 Initial Community Engagement Plan (Developmental Disabilities Administration) 10-660 Community Engagement 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration) 10-660 Initial Community Engagement Plan (Developmental Disabilities Administration) 10-661 Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration) 10-661 Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration) 10-662 Equine Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration) 10-662 Equine Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration) 10-663 Existing Companion Home (CH) Movers Checklist (Developmental Disabilities Administration) 10-664 New or Update Provider Information Worksheet (Developmental Disabilities Administration) 10-665 Alternative Living Provider Application (Developmental Disabilities Administration) 10-666 Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration) 10-668 PASRR Level 2 Evaluation and Determination (Developmental Disabilities Administration) 10-669 Out-of-Home Services (OHS) Transition Checklist (Developmental Disabilities Administrations) 10-670 Nursing Home Facility License Application (Aging and Long-Term Support Administration) 10-671 Intensive Habilitation Services for Children Certification Evaluation (Developmental Disabilities Administration) 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 11-055 Acknowledgement of My Responsibilities As The Employer of My Individual Providers 11-055 COVID Acknowledgement of My Responsibilities as the Employer of My Individual Providers - Temporary COVID Pandemic Version 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) 11-084 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) 11-112 Pre-ETS (Pre-Employment Transition Services) Job Shadow (Division of Vocational Rehabilitation) 11-114 Student Workshop Roster 11-118 Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation)
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11-119 Informational Interview Worksheet (Division of Vocational Rehabilitation)
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  • English ()
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) 11-149 Division of Vocational Rehabilitation (DVR) Customer Job Seeker Accommodation Worksheet 11-152 Forensic Navigator to Inpatient - Referral Information Form (RIF) (Office of Forensic Mental Health Services) 11-153 Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services) 11-154 Personal Pathway 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 12-212 Waiver of Administrative Disqualification Hearing (Community Services Division) 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 (BHPC) Request for MCO Funding (Aging and Long-Term Support Administration) 13-713 Fast Track Service Agreement 13-734 Documentation of First Use of Medicaid Benefits (DDA) 13-738 DDA / DCYF Request to Cost Share (Developmental Disabilities Administration) (Department of Children, Youth, and Families) 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 (Aging and Long-Term Support Administration) 13-917 CCSS Medical / Dental Services Authorization (Community Crisis Stabilization Services) (Developmental Disabilities Administration) 13-919 Weekly Status Update (Competency Restoration Program) (Behavioral Rehabilitation Administration) 13-920 Outpatient Competency Restoration Program (OCRP) Discharge Summary 13-925 Request for Formulary Admission or Deletion (Behavioral Health Administration) 13-925A Non-Formulary Drug Use Request (Behavioral Health Administration) 13-925B Non-Formulary Drug Use Request: Risperidone Consta, Aripiprazole Maintena, Paliperidone Sustenna (Behavioral Health Administration) 13-926 Forensic (6358) Consultation (Behavioral Health Administration) 13-927 Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration) 13-928 Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration) 13-935 State Hospital Triage Consultation and Expedited Admission (TCEA) Request 13-936 Stabilization, Assessment, and Intervention Services (SAIF) Eligibility and Referral (Developmental Disabilities Administration) 14-001 Application for Cash or Food Assistance 14-012 Consent 14-050 Statement of Health, Education, and Employment 14-057 Child Support Referral 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 14-084 Social Service Referral 14-105 Interview Appointment for Applicant (Community Services Division) 14-113 Your Cash and Food Assistance Rights and Responsibilities 14-144A Medical Disability Decision 14-151 Request for DDA Eligibility Determination 14-155 Senior Citizens Service Application 14-223 Statement from School 14-224 Statement from Landlord/Manager 14-225 Acknowledgement of Services 14-238 Client Income Report 14-252 Employment Verification 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 14-381 WorkFirst Individual Responsibility Plan 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 14-426 Protective Payee Payment Plan, Case Assignment, and Closure Notice 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 14-439 Washington State Combined Application Program (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 14-459 Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration) 14-460 Notice of Insufficient Information (Developmental Disabilities Administration) 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 14-478 Aged, Blind, or Disabled (ABD) Program Medical Treatment Participation 14-484 Nurse Delegation: Nursing Visit 14-489 SSIF Introduction Letter 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 14-501 Community Resource Declaration 14-503 Interim Assistance Reimbursement Agreement Cover 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 14-521 Your Rights (Home and Community Services) 14-525 Incapacity Review for Medical Care Services 14-526 ABD and HEN Referral Substance Use Treatment Verification 14-527 Substance Use Disorder Requirements (HEN Referral Program) 14-528 Substance Use Good Cause Appointment Letter (HEN Referral) 14-529 Substance Use Disorder Requirements (ABD / PWA) 14-530 Disability Review 14-532 Authorized Representative 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 14-549 DDA Companion Home Provider Application (Developmental Disabilities Administration) 14-550 Job Foundation Application (Developmental Disabilities Administration) 14-551 Adult Family Homes (AFH) State Civil Penalty Reinvestment Program Grant Application 15-031 Nursing Facility Notice of Action 15-184 Volunteer Chore Service Referral 15-215 AFH Quality Improvement Visit Assessment 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 Certification Evaluation (Developmental Disabilities Administration) 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 15-429A Notice of Decision on Request for School Break Personal Care Exception to Rule 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 15-447 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 15-483 Notification Regarding Request to Exceed Work Week Limit (Home and Community Services) - TRANSLATIONS ONLY 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) 15-501 Notification of Initial Assessment Request (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) 15-564 Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration) 15-565 Nursing Home (NH) Complaint Investigation (CI) Skill Building Tool 15-567 On-the-Job Facility Training Plan Application and Updates (Home and Community Services) 15-568 DDA Alternative Living Provider Orientation (Developmental Disabilities Administration) 15-569 Notice of Termination of Service (Developmental Disabilities Administration) 15-571 Enhanced Services Facility (ESF) Pre-Inspection Preparation 15-572 Enhanced Services Facility (ESF) Request for Documentation 15-573 Enhanced Services Facility (ESF) Resident List 15-574 Enhanced Services Facility (ESF) Resident Characteristic Roster and Sample Selection 15-575 Enhanced Services Facility (ESF) Resident Interview 15-575 Enhanced Services Facility (ESF) Resident Interview 15-576 Enhanced Services Facility (ESF) Other Contact Interview 15-577 Enhanced Services Facility (ESF) Environmental Observations 15-578 Enhanced Services Facility (ESF) Resident Record Review 15-579 Enhanced Services Facility (ESF) Staff and Administrative Record Review 15-580 Enhanced Services Facility (ESF) Training Requirements 15-581 Enhanced Services Facility (ESF) Notes / Worksheets 15-582 Enhanced Services Facility (ESF) Exit Preparation Worksheet 15-583 Enhanced Services Facility (ESF) Food Service Observations and Interviews 15-584 Enhanced Services Facility (ESF) Medication Pass Worksheet 15-585 Enhanced Services Facility (ESF) Staff Schedule Worksheet 15-586 Enhanced Services Facility (ESF) Inspection Packet 16-072 NonAssistance Support Enforcement Information (Division of Child Support) 16-107 Noncustodial Parent's Rights and Responsibilities 16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration 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) 16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative 16-197 Assisted Living Facility Policies and Procedures Attestation
  • Adobe PDF English (Adobe PDF)
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 16-201 New Case / Resource Manager Assessment (Developmental Disabilities Administration) 16-202 5-Day Investigation Report (Developmental Disabilities Administration (DDA) 16-202A Corrective Action Plan (5-Day Investigation) (Developmental Disabilities Administration) 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) 16-242 Ask DSHS 16-243 Community Services Office (CSO) Compliments and Concerns (Economic Services Administration) 16-244 New Freedom Participant Responsibility Agreement 16-245 Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services) 16-246 Your rights as a client of the Developmental Disabilities Administration 16-247 Your Rights and Responsibilities When You Receive MAC or TSOA Services Offered by ALTSA 16-252 For Field Staff Use: Sex Offender Notification to Individual Provider (Home and Community Services) 16-253 For Field Staff Use: Sex Offender Notification to Home Care Agency and Consumer Directed Employer (Home and Community Services) 16-255 For Field Use Only: Sex Offender Notification to Facility (Home and Community Services) 17-011 Forms and Publications Request 17-041 Request for Records 17-063 Authorization 17-116 AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion 17-123 Spoken Language Interpreter Service Appointment Record 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) 17-284 Qualified Sign Language Interpreter Request (Office of Deaf and Hard of Hearing) 17-292 Assistive Communication Technology (ACT) Program Service Request / Work Order for Induction Loops (Office of the Deaf and Hard of Hearing) 17-294 Outpatient Competency Restoration Program Clinical Screening (Behavioral Health Administration) 17-295 Residential Quality Assurance Certification Evaluation Checklist for Companion Homes Providers (Developmental Disabilities Administration) 17-296 Residential Quality Assurance Certification Evaluation Checklist for Alternative Living Providers (Developmental Disabilities Administration) 17-297 Removal and Transport Directive (Behavioral Health Administration) 17-299 Vendor Agreement Information (Behavioral Health Administration) 17-300 BHA Personal Information Release (Behavioral Health Administration) 17-301 Medical Expense Examples (Community Services Division, Economic Services Administration) 17-321 Pre-Admission Screening and Resident Review (PASRR) Equipment Purchase Request 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 18-399 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 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 18-607 Child Care Verification 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) 19-237 Application Budget Summary (Residential Care Services)
  • Excel English (Excel)
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) 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) 21-065 Adult Family Home (AFH) Emergency Evacuation Drill 23-034 Alternative Living Monthly 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) 27-053 Paternity Information 27-057 Provider Referral Letter for Children's Out-of-Home Services (Developmental Disabilities Administration) 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 27-175 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 27-179 Adult Family Home (AFH) Informal Dispute Resolution (IDR) Request (Residential Care Services) 27-182 DSHS Request for Positive Identification – Thumbprint 27-188 Initial Opiate Prescription Informed Consent (Behavioral Health Administration) 27-189 Asset Verification Authorization (Home and Community Services) 27-192 Home and Community Services (HCS) Resumption of Training Attestation 27-194 Complimentary Therapies Agreement (Developmental Disabilities Administration) 27-194 Complimentary Therapies Agreement (Developmental Disabilities Administration) 27-203 Individual Provider (IP) Attestation of Informal Support (Home and Community Services)

Cna Long Term Care Supplemental Statement Verification Form

Source: https://www.dshs.wa.gov/office-of-the-secretary/forms

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