Get Wa Dshs 17-041 2019-2026

The WA DSHS 17-041 form, also known as the request for DSHS records, is essential for individuals seeking access to various records held by the Department of Social and Health Services. This guide will provide clear and supportive instructions on how to complete the form online.

Follow the steps to successfully fill out the WA DSHS 17-041 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide your personal details in section A. Include your name, title, organization (if applicable), mailing address, city, state, zip code, telephone number (with area code), fax number (with area code), and email address.
3. In section B, indicate the DSHS programs you are requesting records from by checking all relevant boxes, including Behavioral Health Administration, Child Support, and any other applicable programs.
4. In section C, specify the name of the person whose records you are requesting, including their last, first, and middle names, along with their date of birth, former names, client identification number, and any other identification number. Additionally, provide details regarding the dates and locations of service, as well as the specific records you are requesting.
5. In section D, if applicable, indicate any other DSHS records you seek, such as licensing records or personnel records. Describe these records in detail, including the date and type.
6. Complete section E to acknowledge understanding that DSHS may charge for copies of records and to indicate any special requests for access to records.
7. Finally, ensure to sign the form in the 'Requested By' section, include the date signed, and provide a witness or notary signature if required. If you are not the subject of the confidential records, state your authority for access.
8. Once all sections are completed, review your form carefully. You can save your changes, download, print, or share the filled-out form as needed.

Complete your WA DSHS 17-041 request for records online today!