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APD-AFH Program Provider Forms

Most of the following forms may also be accessed at DHS/OHA Publications and Forms.

  • DHS 0305
    Residents' Bill of Rights

  • MSC 0189 (05/13)
    Direct Deposit Form - SPD Provider
  • DHS 9030
    AFH Caregiver Preparatory Training - Study Guide​

  • DHS 9030W
    AFH Caregiver Preparatory Training - Workbook

  • MSC 0944
    Adult Foster Home Provider Complaint Form
  • SDS 0346
    AFH Resident Personal Possessions
  • SDS 0347
    AFH Classification Exception Request

  • SDS 0348
    Adult Foster Home Resident Records Checklist

  • SDS 0349
    Substitute Caregiver Orientation Record

  • SDS 0350
    Adult Foster Home Back-up Agreement

  • SDS 0351
    Adult Foster Home Plan of Daily Operation

  • SDS 0352
    Your Right to Make Health Care Decisions

  • SDS 0352A
    Advance Directive

  • SDS 0419B
    Resident/Legal Representative's Authorization to Release Confidential Information

  • SDS 0448 (Word file)
    Adult Foster Home Initial License Application

  • SDS 0448A (Rev. 08/13)
    Adult Foster Home Financial Information

  • SDS 0448B (Word file)
    Adult Foster Home Supplemental Application

  • SDS 0448C (Word file)
    Adult Foster Home License Renewal/Capacity Change Application

  • SDS 0448E
    Complaint Resolution Process Notification

  • SDS 0448F
    AFH Applicant Verification of Financial Resources

  • SDS 0448L (Word file)
    Limited Adult Foster Home Application

  • SDS 0448V (Word file)
    Adult Foster Home Ventilator-Assisted Care License Application

  • SDS 0471
    Notice of Potential Default, Foreclosure or Eviction on Property Used by the AFH Licensee

  • SDS 0490
    Special Needs Resident Admission Review

  • SDS 0511F
    Fire and Life Safety in Adult Foster Homes

  • SDS 0514A
    Exception Request Worksheet (payment exception)

  • SDS 0516
    AFH Initial Inspection

  • SDS 0518
    Important Telephone Numbers (for posting)

  • SDS 0519
    Adult Foster Home Complaint Procedure and Fair Housing Notice
    Please access this form through your local Adult Foster Home Licensing Office

  • SDS 0713
    Resident Account Record

  • SDS 0812A
    Medication Administration Record (PRN)

  • SDS 0901 - (4/2014)
    Adult Foster Home Notice of Resident Move, Transfer or Discharge

  • SDS 0902
    General Information and Screening Assessment

  • SDS 0902A
    Emergency Contact Information

  • SDS 0903
    Health History and Physician / Nurse Practitioner's Statement

  • SDS 0906N
    Monitoring Device Notice (Available through Forms Branch Ordering System (FBOS) Only)
    There should be a designated person in each DHS office who is responsible for ordering forms through this system.

  • SDS 0913
    Notice of Right to Receive a Long-Term Care Assessment

  • SDS 1510
    Request for AFH Training Credit - Instructor's or Sponsor's Form

  • SDS 1513
    Request for AFH Training Credit - AFH Provider Form

Contact Us

apd.afhteam@state.or.us

Note: If you have a disability and need a document on this Web site to be provided to you in another format, please send an email to dhs.forms@state.or.us or call the Office of Communication Resources (OCR) at 503-378-3486, for TTY call 503-378-3523. If you know of others who need this accommodation, please let them know it is available

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