Form Dshs 27 059 PDF Details

As a professional in the service industry, you know that it is important to keep up with changes in regulations. Recently, the Department of Social and Health Services (DSHS) updated Form Dshs 27-059. This form is used to request authorization for services for clients who are not Medicaid eligible or do not have other insurance coverage. The updates include clarifications about allowable services, as well as changes related to the new managed care programs. Make sure you are familiar with these changes so that you can provide appropriate services to your clients. You can find more information on the DSHS website at

Form NameForm Dshs 27 059
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesLearners, 2012, OCA, Weekday

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5. Date of Birth (MM/DD/YYYY)
6. Birthplace (State/Country)
7. Height (Feet/Inches)
8. Weight (Pounds)
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Fingerprint Appointment

Use this form to assist in scheduling a

Department of Social and Health Services fingerprint appointment.

Section 1: To be completed by the requesting agency

1.The agency requesting a fingerprint check must provide the following numbers:

BCCU Account Number:BCCU Inquiry ID/OCA Number:

Section 2: Information to gather BEFORE scheduling a fingerprint appointment

Be prepared to provide the information from Section 1 AND the information below when scheduling your fingerprint appointment.

1. Name (Last, First, Middle)

2. Address (Street, City, State, Zip Code)

3. Daytime Phone (Area Code and Number)

4. Social Security Number (Optional)

9. SEX

Male Female

10. RACE

Caucasian or other Hispanic culture


Asian or Pacific Islander

American Indian, First Nations, Eskimo, or Alaskan Native


Section 3: Fill out this section WHILE scheduling your fingerprint appointment

1.Go to or call 1-888-771-5097 to schedule your fingerprint appointment.

2.Use this space to write down the date, time and location of your fingerprint appointment:

Date / Weekday:




Location / Address:




Section 4: Personal Identification

You must bring one of the following NON-EXPIRED Government Issued PICTURE ID options with you to your fingerprint appointment.

Government Issued PICTURE ID:

US Driver’s License, or any Federal, State, or Local Government issued ID (Including a Washington State Learner’s Permit)

Any US Armed Services ID (Army, Air Force, Navy, Marines, etc…)

US Passport

Foreign Passport (with photo and signature)

Federally Recognized Tribal ID

All ID must be current. Expired identification WILL NOT be accepted unless you can prove that you are in the process of renewing it.