WA DSHS 17-041 2011 free printable template

Request for DSS Records A. REQUEST FOR DSS RECORDS BY: NAME LAST FIRST MIDDLE TITLE ORGANIZATION OR BUSINESS NAME IF APPLICABLE MAILING ADDRESS CITY TELEPHONE NUMBER (INCLUDE AREA CODE) STATE FAX

How to fill out WA DSHS 17-041

How to fill out WA DSHS 17-041

1. Gather all necessary documentation, including identification and proof of income.
2. Open the WA DSHS 17-041 form and read the instructions carefully.
3. Fill out your personal information in the designated sections, including name, address, and contact information.
4. Provide information regarding household members, including their names and relationship to you.
5. Complete the income section, detailing all sources of income and amounts.
6. Answer any additional questions regarding expenses or special circumstances.
7. Review the form for accuracy and completeness.
8. Sign and date the form where required.
9. Submit the form as per the instructions, either by mail or online.

Who needs WA DSHS 17-041?

1. Individuals or families applying for public assistance benefits in Washington State.
2. Those seeking help with financial support, medical assistance, or food assistance programs.

People Also Ask about

What is the DSHS stop work form for Washington state?

Stop Work Questionnaire (form 14-438) This form is used when you stop work or self employment. The form should be signed by you but must be completed by your employer. Your employer can also complete this form On-Line.

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.

What is the phone number for the Washington Connection DSHS?

Call us between 8AM and 3PM, Monday through Friday, at 1-877-501-2233; or. Visit us in person from 8AM-3PM, Monday through Friday at any local office. You can use the office locator to find your local DSHS Community Services Office.

How do I get my medical records in Washington state?

To learn what's required to obtain your medical records, call the provider's office or visit the health information management (HIM) department. Authorization forms may also be available online. When picking up your records, be sure to bring a government-issued photo ID.

How to look up criminal records for free in Washington state?

One of the fastest ways to locate and obtain Washington criminal records is to visit the Washington State Patrol website. Visit the Washington State Patrol website. Click on 'Criminal History Records' Click on 'Online' Visit the 'WATCH' website. Create a new account. Choose the type of search.

What is the time limit for a response to a public records request in Washington?

State and local government agencies are required by RCW 42.56. 520 to respond to a public records request within five business days of receiving the request by doing one of the following: Providing for inspection and/or copying of the records requested.

What is the open records law in Washington state?

Washington law (Chapter 42.56 RCW) requires that identifiable public records be made available to members of the public for inspection and copying upon request. Only records that are exempt by law may be withheld from disclosure. The Act also requires that the public records requested are "identifiable".

What is a public record Washington State?

A public record is defined in RCW 42.56. 010(3) as any writing that is prepared, owned, used, or retained by any state or local government agency, and which contains information that relates to the conduct of government, or the performance of any governmental or proprietary function.

How do I request records in Washington state?

The more precisely you identify the record you seek, the more efficient and effective we can be in locating and providing the appropriate documents. If you need assistance submitting your request, please call 360-725-2733.

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What is WA DSHS 17-041?

WA DSHS 17-041 is a form used by the Washington Department of Social and Health Services for reporting certain information, often related to healthcare or social services.

Who is required to file WA DSHS 17-041?

Individuals or organizations that are involved in specific services or programs regulated by the Washington DSHS are required to file WA DSHS 17-041.

How to fill out WA DSHS 17-041?

To fill out WA DSHS 17-041, follow the instructions provided on the form, ensuring that all required fields are completed accurately, and submit it according to the guidelines specified.

What is the purpose of WA DSHS 17-041?

The purpose of WA DSHS 17-041 is to collect necessary data that helps the DSHS monitor and evaluate the services provided to clients and ensure compliance with regulations.

What information must be reported on WA DSHS 17-041?

The information that must be reported on WA DSHS 17-041 includes specific client data, service details, and any other information that the DSHS requires to effectively manage and assess service delivery.