Form Dshs 02 516 PDF Details

The purpose of this blog post is to provide you with information on a new DHS form that must be completed in order to claim state benefits. Form Dshs 02 516 is the new form that replaces the former Form 502. The replacement of this form was necessitated by recent changes to state law, so it is important that everyone who wishes to claim state benefits completes this form and submits it to the appropriate agency. We will go over the specifics of what this form entails and how to complete it in the subsequent sections of this post. Please note that while we will try our best to provide up-to-date information, rules and regulations surrounding benefits claims may change at any time, so please consult with your local DHS office for the most accurate information. Thank you for your interest in this topic!

QuestionAnswer
Form NameForm Dshs 02 516
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswashington dshs inventory, resident inventory form, resident inventory sheet, dshs home personal inventory

Form Preview Example

AGING AND LONG-TERM SUPPORT ADMINISTRATION (ALTSA)

Adult Family Home Resident Personal Belongings Inventory

WAC 388-76-10320

Instructions: Provider or Resident Manager completes upon admission. The Provider/Resident Manager and the resident or the resident’s guardian or agent sign. File in the resident’s record. Records and information concerning each person in care shall be maintained in such a manner as to preserve confidentiality.

RESIDENT’S NAME

NAME OF RESIDENT’S GUARDIAN

DATE OF ADMISSION

 

 

 

CONTACT LENSES

DENTURES

 

 

 

 

EYE GLASSES

HEARING AID

 

 

 

 

JEWELRY

WATCH

 

 

 

 

MONEY/CHECKBOOK/CREDIT CARDS

OTHER

 

 

 

 

 

 

CLOTHING LIST

NUMBER

ITEM

DESCRIPTION

 

Bathrobe

 

 

Belt

 

 

Blouse

 

 

Brassiere

 

 

Coat

 

 

Dress

 

 

Girdle

 

 

Gloves

 

 

Handkerchief

 

 

Hat

 

 

House coat

 

 

Necktie

 

 

Nightgown

 

 

Pajamas

 

 

Pants

 

 

Shirts

 

 

Shoes

 

 

Skirts

 

 

Slippers

 

 

Slips

 

 

Socks

 

 

Stockings

 

 

Suit

 

 

Suspenders

 

 

Sweater

 

 

Undershirt

 

 

Underpants

 

 

Underwear - long

 

 

Vests

 

 

Other:

 

 

 

MISCELLANEOUS

NUMBER

ITEM

DESCRIPTION

 

Brush

 

 

Cane or crutches

 

 

Clock

 

 

Luggage

 

 

Radio

 

 

Television (model and serial number)

 

 

Walker

 

 

Wheelchair (model and serial number)

 

 

Other:

 

Statement: I have read and agree that this is an accurate list of my belongings.

PROVIDER’S/RESIDENT MANAGER’S SIGNATURE DATE

RESIDENT’S OR GUARDIAN’S SIGNATURE

DATE

 

 

DSHS 02-516 (REV. 07/2017)

How to Edit Form Dshs 02 516 Online for Free

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Part number 1 of submitting resident inventory sheet

2. Once your current task is complete, take the next step – fill out all of these fields - NUMBER, NUMBER, Bathrobe Belt Blouse Brassiere, MISCELLANEOUS, DESCRIPTION, ITEM, Brush Cane or crutches Clock, Statement I have read and agree, RESIDENTS OR GUARDIANS SIGNATURE, DATE, DATE, and DSHS REV with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Completing part 2 of resident inventory sheet

Always be very attentive when filling out Statement I have read and agree and DATE, since this is where most people make a few mistakes.

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