DSHS Form 14-526 "Abd and Hen Referral Substance Use Treatment Verification" - Washington

What Is DSHS Form 14-526?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2021;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 14-526 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 14-526 "Abd and Hen Referral Substance Use Treatment Verification" - Washington

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STATE OF WASHINGTON
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
Date:
Client ID:
Case Worker:
Language:
To remain eligible for the Aged, Blind, or Disabled (ABD) or the Housing and Essential Needs (HEN)
Referral program, you must participate in substance use disorder treatment.
Your ABD or HEN Referral eligibility may end if you do not participate in substance use disorder
treatment without good cause per WAC 388-449-0220 and 388-447-0120.
Please ask your substance use treatment provider to contact me by phone to verify your
participation in treatment. They may also complete this form. If your provider completes this form,
please return this form by
.
Return to:
Phone:
Fax:
This section is completed by your substance use treatment provider:
was seen for an
assessment or
treatment on the following dates:
CLIENT NAME
Is this client participating in
inpatient treatment or
outpatient treatment?
When is the client scheduled to complete their treatment program?
Do you have any recommendations on how we can support the client’s participation in treatment or
any other comments?
NAME
DATE
TITLE
PHONE NUMBER
AGENCY
ADDRESS
ABD AND HEN REFERRAL SUBSTANCE USE TREATMENT VERIFICATION
DSHS 14-526 (REV. 03/2021)
STATE OF WASHINGTON
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
Date:
Client ID:
Case Worker:
Language:
To remain eligible for the Aged, Blind, or Disabled (ABD) or the Housing and Essential Needs (HEN)
Referral program, you must participate in substance use disorder treatment.
Your ABD or HEN Referral eligibility may end if you do not participate in substance use disorder
treatment without good cause per WAC 388-449-0220 and 388-447-0120.
Please ask your substance use treatment provider to contact me by phone to verify your
participation in treatment. They may also complete this form. If your provider completes this form,
please return this form by
.
Return to:
Phone:
Fax:
This section is completed by your substance use treatment provider:
was seen for an
assessment or
treatment on the following dates:
CLIENT NAME
Is this client participating in
inpatient treatment or
outpatient treatment?
When is the client scheduled to complete their treatment program?
Do you have any recommendations on how we can support the client’s participation in treatment or
any other comments?
NAME
DATE
TITLE
PHONE NUMBER
AGENCY
ADDRESS
ABD AND HEN REFERRAL SUBSTANCE USE TREATMENT VERIFICATION
DSHS 14-526 (REV. 03/2021)