| 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) | -
 English (Adobe PDF) | |
| 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 | -
 English (Excel) | |
| 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 | - English (Adobe PDF)
| |
| 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) | -
 English (Word) - English ()
| |
| 11-119 | Informational Interview Worksheet (Division of Vocational Rehabilitation) | - English (Word)
- 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 | - 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) | - 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) | | |