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2092
![DSHS Form 22-552 "Discrimination Complaint - Nondiscrimination in the Basic Food Program" - Washington (Somali)](https://data.templateroller.com/pdf_docs_html/2438/24385/2438590/dshs-form-22-552-discrimination-complaint-nondiscrimination-in-the-basic-food-program-washington-somali.png "DSHS Form 22-552 "Discrimination Complaint - Nondiscrimination in the Basic Food Program" - Washington (Somali)")
![DSHS Form 22-552 "Discrimination Complaint - Nondiscrimination in the Basic Food Program" - Washington](https://data.templateroller.com/pdf_docs_html/2438/24385/2438589/dshs-form-22-552-discrimination-complaint-nondiscrimination-in-the-basic-food-program-washington.png "DSHS Form 22-552 "Discrimination Complaint - Nondiscrimination in the Basic Food Program" - Washington")
![DSHS Form 27-043 "New Contractor Intake" - Washington](https://data.templateroller.com/pdf_docs_html/2438/24385/2438550/dshs-form-27-043-new-contractor-intake-washington.png "DSHS Form 27-043 "New Contractor Intake" - Washington")
![DSHS Form 22-552 "Discrimination Complaint - Nondiscrimination in the Basic Food Program" - Washington (Cambodian)](https://data.templateroller.com/pdf_docs_html/2438/24385/2438588/dshs-form-22-552-discrimination-complaint-nondiscrimination-in-the-basic-food-program-washington-cambodian.png "DSHS Form 22-552 "Discrimination Complaint - Nondiscrimination in the Basic Food Program" - Washington (Cambodian)")
![DSHS Form 06-168 "Adult Family Home (Afh) Change in Licensed Bed Capacity - Increase (Residential Care Services)" - Washington](https://data.templateroller.com/pdf_docs_html/2382/23821/2382190/dshs-form-06-168-adult-family-home-afh-change-in-licensed-bed-capacity-increase-residential-care-services-washington.png "DSHS Form 06-168 "Adult Family Home (Afh) Change in Licensed Bed Capacity - Increase (Residential Care Services)" - Washington")
![DSHS Form 27-208 "Declaration to Adult Protective Services" - Washington](https://data.templateroller.com/pdf_docs_html/2438/24385/2438551/dshs-form-27-208-declaration-to-adult-protective-services-washington.png "DSHS Form 27-208 "Declaration to Adult Protective Services" - Washington")
![DSHS Form 11-166 Exhibit K "Contractor Employee(S) to Provide IL Services and Service(S) Approved" - Washington](https://data.templateroller.com/pdf_docs_html/2382/23821/2382192/dshs-form-11-166-exhibit-k-contractor-employee-s-to-provide-il-services-and-service-s-approved-washington.png "DSHS Form 11-166 Exhibit K "Contractor Employee(S) to Provide IL Services and Service(S) Approved" - Washington")
![DSHS Form 11-163 Exhibit B "Applicant Certification and Assurances" - Washington](https://data.templateroller.com/pdf_docs_html/2382/23821/2382191/dshs-form-11-163-exhibit-b-applicant-certification-and-assurances-washington.png "DSHS Form 11-163 Exhibit B "Applicant Certification and Assurances" - Washington")
DSHS Form 11-163 Exhibit B "Applicant Certification and Assurances" - Washington
Size: 107 KB
1 page
![DSHS Form 14-443 "Financial/Social Services Communication" - Washington](https://data.templateroller.com/pdf_docs_html/2317/23172/2317208/dshs-form-14-443-financial-social-services-communication-washington.png "DSHS Form 14-443 "Financial/Social Services Communication" - Washington")
![DSHS Form 10-328 "Residential Site Approval Request" - Washington](https://data.templateroller.com/pdf_docs_html/2317/23171/2317188/dshs-form-10-328-residential-site-approval-request-washington.png "DSHS Form 10-328 "Residential Site Approval Request" - Washington")
![DSHS Formulario 16-245 "Lista De Verificacion De Procedimientos De Practica De Habilidades Para Asistentes De Atencion En El Hogar - Aprobada Por El Dshs" - Washington (Spanish)](https://data.templateroller.com/pdf_docs_html/2317/23172/2317265/dshs-formulario-16-245-lista-de-verificacion-de-procedimientos-de-practica-de-habilidades-para-asistentes-de-atencion-en-el-hogar-aprobada-por-el-dshs-washington-spanish.png "DSHS Formulario 16-245 "Lista De Verificacion De Procedimientos De Practica De Habilidades Para Asistentes De Atencion En El Hogar - Aprobada Por El Dshs" - Washington (Spanish)")
![DSHS Form 13-911 "Dda Nursing Service Referral" - Washington](https://data.templateroller.com/pdf_docs_html/2317/23172/2317202/dshs-form-13-911-dda-nursing-service-referral-washington.png "DSHS Form 13-911 "Dda Nursing Service Referral" - Washington")
![DSHS Form 11-097 "Service Delivery Outcome Report" - Washington](https://data.templateroller.com/pdf_docs_html/2317/23172/2317200/dshs-form-11-097-service-delivery-outcome-report-washington.png "DSHS Form 11-097 "Service Delivery Outcome Report" - Washington")
![DSHS Form 10-664 "New or Update Provider Information Worksheet" - Washington](https://data.templateroller.com/pdf_docs_html/2317/23171/2317198/dshs-form-10-664-new-or-update-provider-information-worksheet-washington.png "DSHS Form 10-664 "New or Update Provider Information Worksheet" - Washington")
![DSHS Form 11-030 "Service Delivery Outcome Report" - Washington](https://data.templateroller.com/pdf_docs_html/2317/23171/2317199/dshs-form-11-030-service-delivery-outcome-report-washington.png "DSHS Form 11-030 "Service Delivery Outcome Report" - Washington")
![DSHS Form 10-577 Attachment R "Revisits" - Washington](https://data.templateroller.com/pdf_docs_html/2238/22381/2238184/dshs-form-10-577-attachment-r-revisits-washington.png "DSHS Form 10-577 Attachment R "Revisits" - Washington")
![DSHS Form 10-369 Attachment K "Assisted Living Facility Staff Sample/Record Review" - Washington](https://data.templateroller.com/pdf_docs_html/2238/22381/2238180/dshs-form-10-369-attachment-k-assisted-living-facility-staff-sample-record-review-washington.png "DSHS Form 10-369 Attachment K "Assisted Living Facility Staff Sample/Record Review" - Washington")
![DSHS Form 10-365 Attachment G "Assisted Living Facility Resident Interview" - Washington](https://data.templateroller.com/pdf_docs_html/2238/22381/2238177/dshs-form-10-365-attachment-g-assisted-living-facility-resident-interview-washington.png "DSHS Form 10-365 Attachment G "Assisted Living Facility Resident Interview" - Washington")
![DSHS Form 17-299 "Vendor Agreement Information" - Washington](https://data.templateroller.com/pdf_docs_html/2238/22385/2238560/dshs-form-17-299-vendor-agreement-information-washington.png "DSHS Form 17-299 "Vendor Agreement Information" - Washington")
![DSHS Form 10-368 Attachment J "Assisted Living Facility Resident Record Review" - Washington](https://data.templateroller.com/pdf_docs_html/2238/22381/2238179/dshs-form-10-368-attachment-j-assisted-living-facility-resident-record-review-washington.png "DSHS Form 10-368 Attachment J "Assisted Living Facility Resident Record Review" - Washington")
![DSHS Form 10-360 Attachment B "Assisted Living Facility Request for Documentation" - Washington](https://data.templateroller.com/pdf_docs_html/2238/22381/2238178/dshs-form-10-360-attachment-b-assisted-living-facility-request-for-documentation-washington.png "DSHS Form 10-360 Attachment B "Assisted Living Facility Request for Documentation" - Washington")
![DSHS Form 10-487 Attachment Q "Assisted Living Facility Medication Pass Worksheet" - Washington](https://data.templateroller.com/pdf_docs_html/2238/22381/2238183/dshs-form-10-487-attachment-q-assisted-living-facility-medication-pass-worksheet-washington.png "DSHS Form 10-487 Attachment Q "Assisted Living Facility Medication Pass Worksheet" - Washington")
![DSHS Form 14-473 "Inventory for Client and Agency Planning (Icap) Letter" - Washington](https://data.templateroller.com/pdf_docs_html/2317/23172/2317209/dshs-form-14-473-inventory-for-client-and-agency-planning-icap-letter-washington.png "DSHS Form 14-473 "Inventory for Client and Agency Planning (Icap) Letter" - Washington")
![DSHS Form 07-103 "Basic Food Employment and Training (Bfet) Participant Reimbursement" - Washington](https://data.templateroller.com/pdf_docs_html/2317/23171/2317185/dshs-form-07-103-basic-food-employment-and-training-bfet-participant-reimbursement-washington.png "DSHS Form 07-103 "Basic Food Employment and Training (Bfet) Participant Reimbursement" - Washington")
![DSHS Form 27-178 "Aps Administrative Hearing Request" - Washington](https://data.templateroller.com/pdf_docs_html/2317/23174/2317426/dshs-form-27-178-aps-administrative-hearing-request-washington.png "DSHS Form 27-178 "Aps Administrative Hearing Request" - Washington")
![DSHS Formulario 07-103 "Reembolso Para Participantes" - Washington (Spanish)](https://data.templateroller.com/pdf_docs_html/2317/23171/2317186/dshs-formulario-07-103-reembolso-para-participantes-washington-spanish.png "DSHS Formulario 07-103 "Reembolso Para Participantes" - Washington (Spanish)")
![DSHS Form 10-377 "Notification of Age Four (4) Eligibility Expiration" - Washington](https://data.templateroller.com/pdf_docs_html/2317/23171/2317190/dshs-form-10-377-notification-of-age-four-4-eligibility-expiration-washington.png "DSHS Form 10-377 "Notification of Age Four (4) Eligibility Expiration" - Washington")
DSHS Form 10-377 "Notification of Age Four (4) Eligibility Expiration" - Washington
Size: 162 KB
2 pages
![DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Mandinka)](https://data.templateroller.com/pdf_docs_html/2238/22381/2238153/dshs-form-03-387-dshs-notice-of-privacy-practices-for-client-medical-information-washington-mandinka.png "DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Mandinka)")
![DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Korean)](https://data.templateroller.com/pdf_docs_html/2238/22381/2238154/dshs-form-03-387-dshs-notice-of-privacy-practices-for-client-medical-information-washington-korean.png "DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Korean)")
![DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Tongan)](https://data.templateroller.com/pdf_docs_html/2238/22381/2238155/dshs-form-03-387-dshs-notice-of-privacy-practices-for-client-medical-information-washington-tongan.png "DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Tongan)")
![DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Mongolian)](https://data.templateroller.com/pdf_docs_html/2238/22381/2238156/dshs-form-03-387-dshs-notice-of-privacy-practices-for-client-medical-information-washington-mongolian.png "DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Mongolian)")
![DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Samoan)](https://data.templateroller.com/pdf_docs_html/2238/22381/2238157/dshs-form-03-387-dshs-notice-of-privacy-practices-for-client-medical-information-washington-samoan.png "DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Samoan)")
![DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Tigrinya)](https://data.templateroller.com/pdf_docs_html/2238/22381/2238158/dshs-form-03-387-dshs-notice-of-privacy-practices-for-client-medical-information-washington-tigrinya.png "DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Tigrinya)")
![DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Somali)](https://data.templateroller.com/pdf_docs_html/2238/22381/2238159/dshs-form-03-387-dshs-notice-of-privacy-practices-for-client-medical-information-washington-somali.png "DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Somali)")
![DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Russian)](https://data.templateroller.com/pdf_docs_html/2238/22381/2238160/dshs-form-03-387-dshs-notice-of-privacy-practices-for-client-medical-information-washington-russian.png "DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Russian)")
![DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Tagalog)](https://data.templateroller.com/pdf_docs_html/2238/22381/2238163/dshs-form-03-387-dshs-notice-of-privacy-practices-for-client-medical-information-washington-tagalog.png "DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Tagalog)")
![DSHS Formulario 03-387 "Aviso De Practicas De Privacidad De Dshs Para Informacion Medica De Clients" - Washington (Spanish)](https://data.templateroller.com/pdf_docs_html/2238/22381/2238164/dshs-formulario-03-387-aviso-de-practicas-de-privacidad-de-dshs-para-informacion-medica-de-clients-washington-spanish.png "DSHS Formulario 03-387 "Aviso De Practicas De Privacidad De Dshs Para Informacion Medica De Clients" - Washington (Spanish)")
![DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Serbo-Croatian)](https://data.templateroller.com/pdf_docs_html/2238/22381/2238166/dshs-form-03-387-dshs-notice-of-privacy-practices-for-client-medical-information-washington-serbo-croatian.png "DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Serbo-Croatian)")
![DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Ukrainian)](https://data.templateroller.com/pdf_docs_html/2238/22381/2238167/dshs-form-03-387-dshs-notice-of-privacy-practices-for-client-medical-information-washington-ukrainian.png "DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Ukrainian)")
![DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Thai)](https://data.templateroller.com/pdf_docs_html/2238/22381/2238168/dshs-form-03-387-dshs-notice-of-privacy-practices-for-client-medical-information-washington-thai.png "DSHS Form 03-387 "Dshs Notice of Privacy Practices for Client Medical Information" - Washington (Thai)")