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Get WA DSHS 27-122 2015

Tracting. If this printout is not available, you must provide the new copy of your SS card before contracting can be completed. HCS / AAA / DDA INDIVIDUAL PROVIDER CONTRACTOR INTAKE DSHS 27-122 (REV. 12/2015) 2. Specific Client Information: If you intend to provide services to a specific individual, state his/her name here. 3. Suitability: Individual Providers must complete and follow the directions contained in this section. If you have been suspended or debarred from providing services under.

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