Medial Assistant-Registered Appliation Paket Contents: 1. 651-001...Contents List/SSN Information/Mailing Information...1 page 2. 651-002...Appliation Instrutions Cheklist...2 pages 3. 651-003...Credentialing Requirements...1 page 4. 651-004...Medial Assistant-Registered Appliation...5 pages 5. 651-005...Medial Assistant-Registered Healthare Pratitioner Endorsement...3 pages 6. 651-006...Out-of-State Credential Verifiation Form...2 pages 7. RCW/WAC and Online Website Links...1 page Important Soial Seurity Number Information: You are required by state and federal law to provide a soial seurity number with your appliation. If you do not have a soial seurity number at the time you send in this appliation, please read, omplete, and return this form with your appliation. A U.S. Individual Taxpayer Identifiation Number (ITIN) or a Canadian Soial Insurane Number (SIN) annot be substituted. In order to proess your request: Mail your appliation with initial doumentation and your hek or money order payable to: Send other douments not sent with initial appliation to: Department of Health Medial Assistant Credentialing P.O. Box 1099 P.O. Box 47877 Olympia, WA 98507-1099 Olympia, WA 98504-7877 Contat us: 360-236-4700 DOH 651-001 July 2015
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Important bakground hek information: Washington State law authorizes the Department of Health to obtain fingerprint-based bakground heks for liensing purposes. This hek may be through the Washington State Patrol and the Federal Bureau of Investigation (FBI). This may be required if you have lived in another state or if you have a riminal reord in Washington State. This would be at your own expense. All information should be printed learly in blue or blak ink. It is your responsibility to submit the required forms. If you are applying for an initial registration you must pay the appliation fee. (This fee is non-refundable). You an hek the online fee page for urrent fees. If you are applying for an expired registration reissuane you must pay the following: Pay Appliation Fee. Appliation Instrutions Cheklist Pay Late Penalty Fee. Pay Current Renewal Fee. 1. Demographi Information: Soial Seurity Number: You must list your soial seurity number on your appliation. Please all the Customer Servie Center at 360-236-4700 if you do not have one. National Provider Identifier Number (NPI): The National Provider Identifier (NPI) is a standard unique identifier for health are professionals available from the Federal Centers for Mediare and Mediaid Servies. The NPI is a 10 digit numeri identifier. If you have a NPI number, provide this on your appliation. Legal Name: List your full name: first, middle, and last. Definition of Legal Name: Legal name is the name appearing on your offiial ertifiate of birth or, if your name has hanged sine birth, on an offiial marriage ertifiate or an order by a ourt. The ourt must have legal authority to hange your name. We may ask you to prove your legal name. If you use any name other than your legal name on this form, your appliation may be denied. Birth date: Provide the month, day, and year you were born. Birth plae: Provide the ity, state, and ountry where you were born. Address: List the address we should use to send any information about your registration. Be sure to inlude the ity, state, zip ode, ounty, and ountry. This will be your permanent address with Department of Health until we have been notified of a hange, See WAC 246-12-310. Phone, Fax and Cell Numbers: Enter your phone, fax and ell numbers, if you have them. Email: Enter your email address, if you have one. DOH 651-002 July 2015 Page 1 of 2
Other Name(s): Indiate whether you are known or have been known under any other names. If you have a name hange, you must notify the Department of Health in writing. You must inlude proof of this hange. See WAC 246-12-300. 2. Personal Data Questions: All appliants must answer the same personal data questions. They are foused on your fitness to pratie the essential skills of this profession. If you answer yes to any questions in this setion, you must provide an appropriate explanation. You must provide the doumentation listed in the note after the questions. If you do not provide this, your appliation is inomplete and it will not be onsidered. Question 5 inludes misdemeanors, gross misdemeanors and felonies. You do not have to answer yes if you have been ited for traffi infrations. You an obtain opies of ourt reords through the ounty ourthouse where the onvition, plea, deferred sentene, or suspended sentene was entered. Another jurisdition means any other ountry, state, federal territory, or military authority. 3. Experiene: List in date order your professional work experiene. Attah additional ompleted pages if you need more spae. 4. Other Liense, Certifiation, or Registration: List all states where you hold or have held a redential. 5. Qualifiations and Training Attestation: You must meet the Qualifiation and Training Requirements. You must sign and date this as proof of ompletion. 6. Aids Eduation and Training Attestation: Read the AIDS eduation and training attestation. AIDS training may inlude selfstudy, diret patient are, ourses, or formal training. A minimum of seven hours is required. Course ontent an be found in WAC 246-12-270. 7. Appliant Attestation and Signature: You must sign and date this for us to proess the appliation. Notie to Spouses and Registered Domesti Partners of Military Personnel Transferring to Washington Under state law, a spouse or registered domesti partner of military personnel transferring to Washington may reeive his or her health professional liense more quikly. In order for us to do this, please submit the required military doumentation with your appliation for liensure found on your profession appliations and forms page. DOH 651-002 July 2015 Page 2 of 2
Credentialing Requirements Thank you for applying to beome a medial assistant-registered in Washington State. An appliation for registration as a medial assistant-registered who applies to the department within seven days of employment by the endorsing Healthare pratitioner, lini or group pratie may work as a medial assistant-registered for up to sixty days while the appliation is proessed. Note: The appliant must stop working on the sixtieth day of employment if the registration has not been granted for any reason. In order to qualify for registration you must omplete the following: Complete and submit the appliation, with a original signature, date, and fee. Sign and date the appliation as proof of: Completion of high shool eduation or its equivalent. The ability to read, write, and onverse in the English language. Experiene: List in date order your professional work experiene. Attah additional ompleted pages if you need more spae. A medial assistant-registration may be issued if you have a urrent endorsement from a healthare pratitioner, lini, or group pratie. In order to be endorsed, you must: Have a urrent endorsement to perform speifi medial tasks signed by a healthare pratitioner or representative of a lini or group pratie filed with the department. You may only perform the medial tasks listed in your urrent attestation for endorsement. Your endorsement is valid as long as you are ontinuously employed as a medial assistant-registered by the same Healthare pratitioner, lini, or group pratie and you renew your registration. Your registration based on an endorsement by a healthare pratitioner, lini, or group pratie is not transferable to another healthare pratitioner, lini, or group pratie. Seven hours of AIDS eduation and training as required under WAC 246-827. Out-of-State Credential Verifiation form sent to eah state where you hold or have held a redential. The state will omplete its portion of the verifiation form and mail it diretly bak to Washington State. DOH 651-003 July 2015
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Revenue: 0252625081 Medial Assistant-Registered Credential Appliation 1. Demographi Information Soial Seurity Number (SSN) (If you do not have a SSN, see instrutions) Date Stamp Here Please print learly. It is the responsibility of the appliant to submit all supporting doumentation. Failure to do so may result in a delay in proessing your appliation. National Provider Identifier Number (NPI) (Enter 10 digit number) Male Female Name First Middle Last Birth date (mm/dd/yyyy) Plae of Birth City State Country Address City State Zip Code County Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #) Email Address Have you ever been known under any other name(s)? If yes, list name(s): Will douments be reeived in another name? If yes, list name(s): Faility Information Faility Name Faility Mailing Address City State Zip Code County DOH 651-004 July 2015 Page 1 of 5
2. Personal Data Questions Yes No 1. Do you have a medial ondition whih in any way impairs or limits your ability to pratie your profession with reasonable skill and safety? If yes, please attah explanation... Medial Condition inludes physiologial, mental or psyhologial onditions or disorders, suh as, but not limited to orthopedi, visual, speeh, and hearing impairments, erebral palsy, epilepsy, musular dystrophy, multiple slerosis, aner, heart disease, diabetes, intelletual disabilities, emotional or mental illness, speifi learning disabilities, HIV disease, tuberulosis, drug addition, and aloholism. If you answered yes to question 1, explain: 1a. How your treatment has redued or eliminated the limitations aused by your medial ondition. 1b. How your field of pratie, the setting or manner of pratie has redued or eliminated the limitations aused by your medial ondition. Note: If you answered yes to question 1, the liensing authority will assess the nature, severity, and the duration of the risks assoiated with the ongoing medial ondition and the ongoing treatment to determine whether your liense should be restrited, onditions imposed, or no liense issued. The liensing authority may require you to undergo one or more mental, physial or psyhologial examination(s). This would be at your own expense. By submitting this appliation, you give onsent to suh an examination(s). You also agree the examination report(s) may be provided to the liensing authority. You waive all laims based on onfidentiality or privileged ommuniation. If you do not submit to a required examination(s) or provide the report(s) to the liensing authority, your appliation may be denied. 2. Do you urrently use hemial substane(s) in any way whih impair or limit your ability to pratie your profession with reasonable skill and safety? If yes, please explain... Currently means within the past two years. Chemial substanes inlude alohol, drugs, or mediations, whether taken legally or illegally. 3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or frotteurism?... 4. Are you urrently engaged in the illegal use of ontrolled substanes?... Currently means within the past two years. Illegal use of ontrolled substanes is the use of ontrolled substanes (e.g., heroin, oaine) not obtained legally or taken aording to the diretions of a liensed Healthare pratitioner. Note: If you answer yes to any of the remaining questions, provide an explanation and ertified opies of all judgments, deisions, orders, agreements and surrenders. The department does riminal bakground heks on all appliants. 5. Have you ever been onvited, entered a plea of guilty, no ontest, or a similar plea, or had proseution or a sentene deferred or suspended as an adult or juvenile in any state or jurisdition?... Note: If you answered yes to question 5, you must send ertified opies of all ourt douments related to your riminal history with your appliation. If you do not provide the douments, your appliation is inomplete and will not be onsidered. To protet the publi, the department onsiders riminal history. A riminal history may not automatially bar you from obtaining a redential. However, failure to report riminal history may result in extra ost to you and the appliation may be delayed or denied. DOH 651-004 July 2015 Page 2 of 5
2. Personal Data Questions (Cont.) Yes No 6. Have you ever been found in any ivil, administrative or riminal proeeding to have: a. Possessed, used, presribed for use, or distributed ontrolled substanes or legend drugs in any way other than for legitimate or therapeuti purposes?... b. Diverted ontrolled substanes or legend drugs?.... Violated any drug law?... d. Presribed ontrolled substanes for yourself?... 7. Have you ever been found in any proeeding to have violated any state or federal law or rule regulating the pratie of a Healthare profession? If yes, please attah an explanation and provide opies of all judgments, deisions, and agreements?... 8. Have you ever had any liense, ertifiate, registration or other privilege to pratie a Healthare profession denied, revoked, suspended, or restrited by a state, federal, or foreign authority?... 9. Have you ever surrendered a redential like those listed in number 8, in onnetion with or to avoid ation by a state, federal, or foreign authority?... 10. Have you ever been named in any ivil suit or suffered any ivil judgment for inompetene, negligene, or malpratie in onnetion with the pratie of a Healthare profession?... 11. Have you ever been disqualified from working with vulnerable persons by the Department of Soial and Health Servies (DSHS)?... 3. Training and Experiene List in date order your professional work experiene. Attah additional pages if you need more spae. Full Name, City and State/Shools Attended Degree Earned Attendane Entrane Date Ending Date DOH 651-004 July 2015 Page 3 of 5
4. Other Liense, Certifiation, or Registration List all states, inluding Washington, where redentials are or were held. Credential Method of Liensure State/Jurisdition Credential Type Year Issued Number Exam Endorse Grandparented 5. Qualifiations and Training Attestation I ertify I have ompleted eah of the requirements below. A high shool diploma or equivalent; The ability to read, write, and onverse in the English language. Appliant s Initials Date 6. Aids Eduation and Training Attestation I ertify I have ompleted the minimum of seven hours of eduation in the prevention, transmission and treatment of AIDS, whih inluded the topis of etiology and epidemiology, testing and ounseling, infetion ontrol guidelines, linial manifestations and treatment, legal and ethial issues to inlude onfidentiality, and psyhosoial issues to inlude speial population onsiderations. I understand I must maintain reords doumenting said eduation for two years and be prepared to submit those reords to the department if requested. I understand that should I provide any false information, my liense may be denied, or if issued, suspended or revoked. Appliant s Initials Date DOH 651-004 July 2015 Page 4 of 5
7. Appliant s Attestation I,, delare under penalty of perjury under the laws of the (Name of Appliant) state of Washington that the following is true and orret: I am the person desribed and identified in this appliation. I have read RCW 18.130.170 and RCW 18.130.180 of the Uniform Disiplinary At. I have answered all questions truthfully and ompletely. The doumentation provided in support of my appliation is aurate to the best of my knowledge. I understand the Department of Health may require more information before deiding on my appliation. The department may independently hek onvition reords with state or federal databases. I authorize the release of any files or reords the department requires to proess this appliation. This inludes information from all hospitals, eduational or other organizations, my referenes, and past and present employers and business and professional assoiates. It also inludes information from federal, state, loal or foreign government agenies. I understand that I must inform the department of any past, urrent or future riminal harges or onvitions. I will also inform the department of any physial or mental onditions that jeopardize my ability to provide quality Healthare. If requested, I will authorize my health providers to release to the department information on my health, inluding mental health and any substane abuse treatment. Dated at (mm/dd/yyyy) (City, state) by: (Original Signature of Appliant) DOH 651-004 July 2015 Page 5 of 5
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Medial Assistant Credentialing P.O. Box 47877 Olympia, WA 98504-7877 360-236-4700 Medial Assistant-Registered Healthare Pratitioner Endorsement Appliant: Use this form for medial assistant-registered endorsement. All information should be printed learly in blue or blak ink. This form may be dupliated. An endorsement must be signed by a healthare pratitioner as defined in RCW 18.360.010. You may only perform the medial tasks listed in your urrent attestation for endorsement, as listed in RCW 18.360.050(4). Do not add additional tasks to this form. A new endorsement form must be submitted within 30 days if your tasks hange. Your endorsement is valid as long as you are ontinuously employed as a medial assistant-registered by the same healthare pratitioner, lini or group and you renew your registration. Your endorsement is not transferable to another healthare pratitioner, lini or group pratie. Fill out setion one and forward to the healthare pratitioner for ompletion of setions two through four. 1. Print learly: Name Last First Middle Birth Date (mm/dd/yyyy) Soial Seurity Number Address City State Zip Code 2. Healthare Pratitioner: Appliant Date of Hire: (mm/dd/yyyy) The above individual seeks verifiation of supervised medial assisting and endorsement as a medial assistant-registered. Please omplete the following: Healthare Pratitioner (hek all that apply) MD DO MD-PA DO-PA ARNP RN DPM ND OD Healthare Pratitioner Name Phone (enter 10 digit #) Healthare Pratitioner Liense Number Liense Expiration Date Pratie Setting (Chek One): Group Pratie Clini Physiian s Offie Hospital Other Healthare Faility DOH 651-005 July 2015 Page 1 of 3
3. Faility Information: Faility Name Faility Mailing Address City State Zip Code 4. Healthare Pratitioner Attestation: I attest that will assist with patient are and perform administrative and linial proedures. I attest appropriate supervision will be provided to the medial assistant-registered in arrying out the proedures delegated. I attest the medial assistant-registered has demonstrated ompeteny to perform the following tasks: a. Fundamental proedures: Yes No i. Wrapping items for autolaving... ii. Proedures for sterilizing equipment and instruments... iii. Disposing of biohazardous materials... iv. Pratiing standard preautions... b. Clinial proedures: i. Preparing for sterile proedures... ii. Taking vital signs... iii. Preparing patients for examination... iv. Observing and reporting patients signs or symptoms.... Speimen olletion: Healthare Pratitioner (print) Medial Assistant-Registered Name (print) i. Obtaining speimens for mirobiologial testing... ii. Instruting patients in proper tehnique to ollet urine and feal speimens... iii. Finger and/or heel stik to ollet a blood speimen... DOH 651-005 July 2015 Page 2 of 3
d. Patient are: i. Telephone and in-person sreening limited to intake and gathering of information without requiring the exerise of judgment based on linial knowledge... ii. Obtaining vital signs... iii. Obtaining and reording patient history... iv. Preparing and maintaining examination and treatment areas... v. Preparing patients for and assisting with routine and speialty examinations, proedures, treatments, and minor offie surgeries utilizing no more than loal anestheti... vi. Maintaining medial and immunization reords... vii. Sreening and following up on test results as direted by a healthare pratitioner... e. i. Tests waived under the federal linial laboratory improvement (CLIA) amendments program... ii. Moderate omplexity tests if the medial assistant-registered meets standards for personnel qualifiations and responsibilities in ompliane with federal regulation for nonwaived testing... f. Administering eye drops, topial ointments, and vaines, inluding ombination or multidose vaines... g. Urethral atheterization when appropriately trained... F I attest that the above information is aurate and omplete to the best of my knowledge. I understand that the Department of Health may request additional information, if it is needed. Original Signature Healthare pratitioner Original Signature Medial Assistant-Registered Date (mm/dd/yyyy) Date (mm/dd/yyyy) DOH 651-005 July 2015 Page 3 of 3
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Medial Assistant Credentialing P.O. Box 47877 Olympia, WA 98504-7877 360-236-4700 Out-of-State Credential Verifiation To Appliant: Please omplete this side of form and send it to the state(s) and/or jurisdition(s) where you are or have been liensed, ertified, or registered. Instrut them to return the form diretly to the address listed above. Liensing agenies normally harge a fee to verify a redential, please hek in advane to help expedite this proess. Name: Last First Middle Mailing Address City State Zip Code Any other names used: Credential Number Date Issued Have the liensing ageny return this ompleted form to the address listed above. This form may be dupliated. DOH 651-006 July 2015 Page 1 of 2
(To be Completed by the Regulatory Ageny) Please omplete this form regarding the appliant listed on the reverse. Submit the ompleted form and any other requested material diretly to this offie at the address on the reverse. We will not aept the form if submitted by the appliant. Thank you. Name of redential holder: Authority providing verifiation: (state, name, and title) Appliant was redentialed by: Date: Written Examination Name of examination: Sore: Other Examination Date: Sore: Name of examination: Is redential urrent: Yes No Expiration Date: Is this individual onsidered to be in good standing in your state? Yes No If no, please attah explanation. Has this redential ever been denied? Yes No Suspended? Yes No Revoked? Yes No Surrendered? Yes No Reinstated? Yes No If yes, please provide a opy of the final order or other doumentation of ation taken. If this redential holder has been disiplined, has he/she suessfully ompleted all requirements and is urrently in good standing? Yes No (SEAL) Signature: Title: Date: DOH 651-006 July 2015 Page 2 of 2
RCW/WAC and Online Website Links RCW/WAC Links Uniform Disiplinary At, RCW 18.130 Administrative Proedure At, RCW 34.05 Medial Assistant Law, RCW 18.360 Medial Assistant Rules, WAC 246-827 On-line AIDS Training Resoures, Referene Page Medial Assistant, Web Page List-Serv To reeive emails regarding important medial assistant information, please join our interested parties on our List-Serv. RCW/WAC and Online Website Links July 2015