ID card designs - Washington State Department of Licensing 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the individual's name, date of birth (DOB), and TABS ID# in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill out the county, address, Medicaid number, phone number, and email. This information helps in processing the request efficiently.
4. Provide details about the current living situation and primary contact person. Include their relationship to the individual and any relevant contact information.
5. Complete sections regarding current OPWDD services and non-OPWDD services. List all services currently received along with provider names and service amounts.
6. In the 'Services Requested' section, check all applicable request types and provide justifications for each service requested. Be specific about how these services support individual goals.
7. Finally, ensure that a care manager signature is included at the end of the form to confirm that a person-centered conversation has occurred.

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