You are not limited to evaluating the presenting condition(s).
ProviderOne: you must be enrolled in ProviderOne to claim reimbursements.
Special test: you are not required to complete any special test of functional capacity to render your professional medical opinion on this form.
Severity: estimate the severity of the diagnosis from 1 (None) to 5 (Severe).
Confidentiality: the information you provide is subject to Washington State Public Disclosure laws and may be released to the client upon request.
| Question | Answer |
|---|---|
| Form Name | DSHS 13-021 |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 12 min |
| Edition | Rev 06/2020 |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | DSHS 13-021, DSHS 13021, 13-021, Physical Functional Evaluation |
| Official source | DSHS 13-021 (Rev 06/2020), Washington State Department of Social and Health Services |
Dshs 13 021 Form isn’t the one you’re looking for?