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Adult family home disclosure of charges

Dshs disclosure form 2026

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4.8 out of 5

263 votes

The document is a disclosure form for Adult Family Homes, required by Washington state law (RCW 70.128.280). It outlines the services and care provided by the home, including personal care, medication services, skilled nursing, specialty care designations, staffing requirements, cultural access, Medicaid policies, and available activities. The form emphasizes that the scope of services may vary based on resident needs and regulatory compliance.

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Click ‘Get Form’ to open the dshs disclosure form in the editor.
Begin by filling out the 'About the Home' section. Provide your license number and any optional statements about your home’s mission and values.
In the 'Personal Care' section, detail the assistance provided for tasks such as eating, toileting, and bathing. Be specific about how you can support residents in these areas.
Next, complete the 'Medication Services' section by outlining the type of medication assistance available at your home.
For 'Skilled Nursing Services', indicate if you provide nursing care directly or through a contracted nurse. Specify any skilled services offered.
Fill out the 'Staffing' section to describe who lives in the home and their roles, including normal staffing levels.
Address cultural or language access needs by noting any accommodations made for diverse backgrounds.
Clarify your Medicaid policy in that section, detailing conditions under which you accept Medicaid payments.
Finally, list activities available for residents in the 'Activities' section before reviewing all entries for accuracy.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (263 Votes)
2014	4.3 Satisfied (41 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How to upload documents to DSHS Washington state?

Look for a second email with subject line: [SECURE] Email Documents to MyDocs@DSHS.WA.GOV Then follow the steps in that message to attach and send your documents. In the future, you can respond to this email to send documents electronically, so you may want to store it in your email inbox.

How do I contact DSHS in Washington state?

Services are available at your local Community Services Office and by phone through the Customer Service Contact Center at 877-501-2233: TTY/TDD users dial 1-800-833-6384 for Washington Relay Service.

Can you email DSHS Washington state?

You may email Jennifer.McDonald@dshs.wa.gov or call (360) 725-1718.

How do I send documents to Snap?

Uploading Documents for SNAP: Quick Steps Log in to your states SNAP web portal. Find the document upload page. Select which document youre uploading in the dropdown menu. Upload the document to the portal.

How to apply for DSHS benefits in Washington?

You may complete an online application by using the WashingtonConnection.org website, applying by phone at 877-501-2233 or going to your local Community Services Office. On WashingtonConnection.org you can: Start a new application. Report a change, such as address, income or family situation.

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