Wa Practitioner Application PDF Details

The Wa practitioner application form is now available on the website of the World Health Organization. This form must be completed by all Wa practitioners seeking recognition and access to the WHO's technical assistance and services. The deadline for submission is October 1st, 2017. Please read the instructions carefully before completing the form.

You'll find it helpful to understand the amount of time you'll need to prepare this wa practitioner application and just how lengthy this document is.

QuestionAnswer
Form NameWa Practitioner Application
Form Length13 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 15 sec
Other nameshow to washington practitioner application, provider washington practitioner application, washington state practitioner applicatio, application washington state practitioner

Form Preview Example

• Curriculum Vitae (Not an acceptable substitute for completing the application. Dates need to be listed in mm/yyyy Format)

Washington Practitioner Application

To use the Washington Practitioner Application (WPA), follow these instructions:

Keep an unsigned and undated copy of the application on file for future requests. When a request is received, send a copy of the completed application, making sure that all information is complete, current and accurate.

Please sign and date pages 11 and 13 .

Please document any YES responses on the Attestation Question page.

Identify the health care related organization(s) to which this application is being submitted in the space provided below.

Attach copies of requested documents each time the application is submitted.

If changes must be made to the completed application, strike out the information and write in the modification, initial and date.

If a section does not apply to you, please check the provided box at the top of the section.

Expect addendums from the requesting organizations for information not included on the WPA.

This application is submitted to:

1.INSTRUCTIONS

This form should be typed or legibly printed in black or blue ink. If more space is needed than provided on original, attach additional sheets and reference the question being answered. Please do not use abbreviations. Current copies of the following documents must be submitted with this application: (all are required for MDs, DOs; as applicable for other health practitioners).

• DEA Certificate

• Face Sheet of Professional Liability Policy or Certificate

** All sections must be completed in their entirety. **

2. PRACTITIONER INFORMATION – Legal Name Required

Last Name: (include suffix; Jr., Sr., III)

First:

Middle:

Degree(s):

List any other name(s) under which you have been known by reference, licensing and or educational institutions:

Home Mailing Address:

City:

State:

State

Zip Code:

xxxxx-xxxx

Home Telephone Number:

 

Pager Number:

 

Cell Phone Number:

E-Mail Address:

(

)

 

 

(

)

 

 

(

)

 

Email address

 

 

 

 

 

 

 

 

 

 

 

Birth Date: (mm/dd/yyyy)

 

Birth Place (city, state,

country):

 

 

 

Citizenship:

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number:

 

 

 

Male

 

Female

Languages Fluently

Spoken by Practitioner:

 

 

 

 

 

 

 

 

 

 

 

Have you ever voluntarily opted-out of Medicare? Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

NPI:

 

 

Medicare Number: (WA)

 

Medicaid (DSHS) Number(s):

L & I Number(s):

 

 

 

 

 

 

 

 

 

Specialty primarily practicing:

 

 

 

 

 

Sub specialties primarily practicing:

Other Professional Interests in Practice, Research, etc.:

Washington Practitioner Application – January 2019

Page 1 of 13

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3.

PRACTICE INFORMATION

 

 

CHECK ALL THAT APPLY

 

 

 

 

 

 

 

Effective Date at PRIMARY Practice location (MM/YY) __________

 

 

 

 

 

 

 

 

Practice Setting

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clinic/Group

Solo Practice

Home Based

Hospital Based

Primary Care Site

Urgent Care

Other

Practitioner Profile

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PCP

Specialist

Check if you are both PCP & OB OB in your practice

Yes

No

Deliveries

Yes

No

 

 

 

 

 

 

 

 

 

Name of Practice / Affiliation or Clinic Name:

 

 

 

Department Name (if hospital based):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Office Street Address:

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

Zip Code:

 

Org. NPI#:

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Appointment Telephone Number:

 

 

 

 

Fax Number:

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

Mailing Address: (if different from above)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Billing Address: (if different from above)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Practice Website

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Manager / Administrator Name:

 

 

 

 

Administration Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

E-mail Address:

 

 

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Credentialing Contact (if different from above):

 

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail Address:

 

 

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

Name Affiliated with Tax ID Number:

 

 

 

 

 

Federal Tax ID Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the office wheelchair accessible?

Yes

 

No

 

 

Office Hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Monday: ________________________

 

Are you accepting new patients?

Yes

No

 

 

 

Have you limited your practice in any way (e.g. 18 years or older?)

Tuesday: ________________________

 

 

Yes

No If yes, please explain:

 

 

 

 

 

Wednesday: ______________________

 

_________________________________________________________

 

Thursday: ________________________

 

_________________________________________________________

 

Friday: __________________________

 

Do you currently supervise ARNP’s or PA’s?

Yes

No

Saturday: ________________________

 

If yes, please provide the name and specialty below:

 

 

Sunday:__________________________

 

_________________________________________________________

 

Do you provide 24 hour coverage?

Yes

No

_________________________________________________________

 

If no, please explain how your patients obtain

Please list languages fluently spoken by office staff:

 

 

advice and care after hours:

 

 

_________________________________________________________

 

_________________________________________

_________________________________________________________

 

_________________________________________

A. Hospital Inpatient Coverage Plan (for those without admitting privileges)

Does Not Apply

Name of Admitting Physician/Practice/Clinic/Group:

Hospital Where privileged:

 

B. Office Covering Practitioners/Call Group

Provider Name, Degree

Specialty

Address

Does Not Apply

Phone Number

Attach a list of additional covering practitioners if needed

Washington Practitioner Application – January 2019

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Effective Date at SECONDARY Practice location (MM/YYYY)

 

 

CHECK ALL THAT APPLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Practice Setting

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clinic/Group

Solo Practice

Home Based

Hospital Based

Primary Care Site

Urgent Care

Other

Practitioner Profile

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PCP

Specialist

Check if you are both PCP & OB OB in your practice

 

Yes

No

Deliveries

Yes

No

 

 

 

 

 

 

Name of Secondary Practice / Affiliation or Clinic Name:

Department Name (if hospital based):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Office Street Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

Zip Code:

 

Org. NPI#

 

 

 

 

 

 

 

 

 

 

 

 

Patient Appointment Telephone Number:

 

 

 

Fax Number:

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

Mailing Address: (if different from above)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Billing Address: (if different from above)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Practice Website

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Manager / Administrator Name:

 

 

 

Administration Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

E-mail Address:

 

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Credentialing Contact (if different from above):

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

E-mail Address:

 

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

Name Affiliated with Tax ID Number:

 

 

 

 

Federal Tax ID Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the office wheelchair accessible?

Yes

 

No

 

Office Hours

 

 

 

 

 

 

 

 

 

Monday: ________________________

 

Are you accepting new patients?

Yes

No

 

 

Have you limited your practice in any way (e.g. 18 years or older?)

Tuesday: ________________________

 

 

Yes

No If yes, please explain:

 

 

 

 

Wednesday: ______________________

 

_________________________________________________________

Thursday: ________________________

 

_________________________________________________________

Friday: __________________________

 

Do you currently supervise ARNP’s or PA’s?

Yes

No

Saturday: ________________________

 

If yes, please provide the name and specialty below:

 

Sunday:__________________________

 

_________________________________________________________

Do you provide 24 hour coverage?

Yes

No

_________________________________________________________

If no, please explain how your patients obtain

Please list languages fluently spoken by office staff:

 

advice and care after hours:

 

 

_________________________________________________________

_________________________________________

_________________________________________________________

_________________________________________

 

 

 

 

 

 

 

 

 

_________________________________________

A.Hospital Inpatient Coverage Plan (for those without admitting privileges)

Does Not Apply

Name of Admitting Physician/Practice/Clinic/Group:

Hospital Where privileged:

 

B. Office Covering Practitioners/Call Group

 

 

Does Not Apply

 

 

 

 

 

 

 

 

 

Provider Name, Degree

Specialty

Address

Phone Number

 

Attach a list of additional covering practitioners if needed

Washington Practitioner Application – January 2019

Page 3 of 13

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Modification to the wording or format of the Washington Practitioner Application may invalidate the application.

LIST OTHER OFFICE LOCATIONS WITH THE ABOVE INFORMATION ON A SEPARATE SHEET

4.PROFESSIONAL LICENSURE, REGISTRATIONS AND CERTIFICATIONS

(Attach Additional Sheet if Necessary)

Washington State Professional License/Registration/Cert

Issue Date:

Expiration Date:

Number:

 

 

Name of Sponsor if required by licensure, (e.g. Physician’s Assistant).

Pharmacists Collaborative Drug Therapy Agreement (CDTA) Number(s):

Drug Enforcement Administration (DEA) Registration Number:

Expiration Date:

 

 

ECFMG Number (applicable to foreign medical graduates):

Date Issued:

 

 

5.ALL OTHER PROFESSIONAL LICENSES, REGISTRATIONS AND CERTIFICATIONS

State:

Lic/Reg/Cert Number:

Date Issued

Exp. Date

Yr. Relinquish

Reason:

 

 

 

 

 

 

State:

Lic/Reg/Cert Number:

Date Issued

Exp. Date

Yr. Relinquish

Reason:

 

 

 

 

 

 

State:

Lic/Reg/Cert Number:

Date Issued

Exp. Date

Yr. Relinquish

Reason:

 

 

 

 

 

 

6. UNDERGRADUATE EDUCATION (Do not abbreviate)

 

Does Not Apply

School/College/University/Vocational Education:

Degree Received(be specific, e.g. BS

 

Graduation Date

 

Biology)

 

 

(mm/yyyy)

 

 

 

 

 

Mailing Address:

City:

State:

 

Zip Code:

 

 

 

 

 

College or University Name:

Degree Received(be

specific, e.g. BS

 

Graduation Date

 

Biology)

 

 

(mm/yyyy)

 

 

 

 

 

Mailing Address:

City:

State:

 

Zip Code:

 

 

 

 

 

7. MASTER DEGREE PROGRAM OR POST GRADUATE EDUCATION

 

Does Not Apply

Institution:

 

 

 

Address

City

State

Zip Code:

 

 

 

 

 

 

 

 

 

Dates Attended (mm/yyyy - mm/yyyy):

Program or Course of Study:

 

 

 

(

 

) - (

 

)

 

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

Faculty Director:

 

 

 

Degree:

 

 

 

 

 

 

 

 

 

 

 

 

8.MEDICAL/PROFESSIONAL EDUCATION (Do not abbreviate)

Medical/Professional School:

 

Start Date:

Graduation Date

Degree Received

 

 

(mm/yyyy)

(mm/yyyy)

 

 

 

 

 

 

Mailing Address:

 

City:

State:

Zip Code:

 

 

 

 

 

Medical/Professional School:

 

Start Date

Graduation Date

Degree Received

 

 

(mm/yyyy)

(mm/yyyy)

 

 

 

 

 

 

Mailing Address:

 

City:

State:

Zip Code:

 

 

 

 

 

Washington Practitioner Application – January 2019

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Modification to the wording or format of the Washington Practitioner Application may invalidate the application.

9. INTERNSHIP/PGYI (Attach Additional Sheet if Necessary)

 

Does Not Apply

 

Institution:

Phone Number:

Fax Number:

Program Director:

 

 

 

 

 

Mailing Address:

City:

State:

Zip Code:

 

 

 

 

 

Type of Internship:

Specialty:

From (mm/yyyy):

To (mm/yyyy):

 

 

 

 

 

10.

RESIDENCIES

(Attach Additional Sheet if Necessary)

 

Does Not Apply

Institution:

 

 

 

Phone Number:

Fax Number:

 

Program Director:

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

City:

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

Type of Residency:

 

 

Specialty:

From (mm/yyyy):

 

To (mm/yyyy):

 

 

 

 

 

 

 

 

Did you successfully complete the program?

Yes

No (If "No", please explain on separate sheet.)

Institution:

 

 

 

Phone Number:

Fax Number:

 

Program Director:

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

City:

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

Type of Residency:

 

 

Specialty:

From (mm/yyyy):

 

To (mm/yyyy):

 

 

 

 

 

 

 

 

Did you successfully complete the program?

Yes

No (If "No", please explain on separate sheet.)

11.

FELLOWSHIPS

 

(Attach Additional Sheet if Necessary)

 

Does Not Apply

 

Institution:

 

 

 

Phone Number:

Fax Number:

 

Program Director:

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

City:

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

Course of Study:

 

 

 

 

From (mm/yyyy):

 

To (mm/yyyy):

 

 

 

 

 

 

 

 

Did you successfully complete the program?

Yes

No (If "No", please explain on separate sheet.)

Institution:

 

 

 

Phone Number:

Fax Number:

 

Program Director:

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

City:

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

Course of Study:

 

 

 

 

From (mm/yyyy):

 

To (mm/yyyy):

 

 

 

 

 

 

 

 

Did you successfully complete the program?

Yes

No (If "No", please explain on separate sheet.)

12.

PRECEPTORSHIP

(Attach Additional Sheet if Necessary)

 

Does Not Apply

 

Institution:

 

 

 

Address:

City:

 

 

State:

Zip Code:

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

Fax Number

 

Email

Address

 

 

(

)

 

 

 

( )

 

 

 

 

 

 

 

 

 

 

Dates Attended (mm/yyyy - mm/yyyy):

Training:

 

Department Chairman:

(

/

) - (

/

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Washington Practitioner Application – January 2019

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Modification to the wording or format of the Washington Practitioner Application may invalidate the application.

13. FACULTY/TEACHING APPOINTMENTS (Attach Additional Sheet if Necessary)

 

 

Does Not Apply

Institution:

 

 

 

 

 

Address:

 

 

 

City:

 

 

 

State:

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

 

 

Fax Number

 

 

 

 

 

 

Email

Address

 

(

)

 

 

 

 

 

( )

 

 

 

 

 

 

 

 

 

 

Dates Attended (mm/yyyy - mm/yyyy):

 

 

Position:

 

 

 

 

 

 

Faculty Director:

 

(

/

) - (

/

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

BOARD CERTIFICATION

 

 

 

 

 

 

 

 

 

 

Does Not Apply

Are you board or otherwise professionally certified?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes If "Yes", please complete

 

 

No If "No", describe your intent for certification, if any, and dates of testing for

below:

 

 

 

 

Certification on separate sheet.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Recertified

Expiration Date

Issuing Board/Entity and State Issued

 

 

Specialty

 

Date Certified

 

 

 

 

 

(if any)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you applied for certification other than those indicated above?

 

 

 

Yes

 

No

 

 

If so, list certification and date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certification number if applicable:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you participate in a specialty which does not have board certification, please indicate specialty:

 

 

 

 

 

 

 

 

 

 

15. OTHER CERTIFICATIONS ACLS, BLS, ATLS, PALS, NALS (e.g., Fluoroscopy, Radiography, etc.)

 

 

(Attach Certificate if Applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type:

 

 

 

 

Number:

 

 

 

 

 

Expiration Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type:

 

 

 

 

Number:

 

 

 

 

 

Expiration Date:

 

 

 

 

 

 

 

 

 

 

 

 

16.

HOSPITAL, MILITARY, & OTHER INSTITUTIONAL AFFILIATIONS

Does Not Apply

 

 

Please list in reverse chronological order (with the current affiliation(s) first) all institutions where you (A) Current Hospital

affiliation, (B) Previous Hospital Affiliations, (C) Current Military Affiliation, (D) Previous Military Affiliations (E) Applications in

process This includes hospitals, surgery centers, institutions, corporations, military assignments, or government agencies. If

more space is needed, attach additional sheet(s). List only affiliations here, list employment in section XVII, Work History.

A. CURRENT HOSPITAL AFFILIATIONS (Do not abbreviate)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Primary Admitting Hospital:

 

 

 

 

 

 

 

Department:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

City, State , Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone number:

 

 

 

 

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

Status (active, provisional, courtesy, temporary, etc.):

 

 

 

Appointment Date (mm/yyyy):

 

 

 

 

 

 

 

 

 

Can you admit / follow clients of your primary, secondary, other practice

locations?

Does Not Apply

 

 

 

Primary practice admits only

 

 

Secondary Practice admits only

 

can admit to for all locations

Name of Secondary Admitting Hospital:

 

 

 

 

 

 

Department:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

City, State, Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone number:

 

 

 

 

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Status:

 

 

 

 

 

 

 

 

 

Appointment Date (mm/yyyy):

 

 

 

 

 

 

 

 

 

Can you admit / follow clients of your primary, secondary, other practice

locations?

Does Not Apply

 

 

 

Primary practice admits only

 

 

Secondary Practice admits only

 

Can admit to for all locations

Washington Practitioner Application – January 2019

 

Page 6 of 13

- 6 -

 

 

 

 

 

 

 

 

Modification to the wording or format of the Washington Practitioner Application may invalidate the application.

Name of Other Institutions:

 

Department:

 

 

 

 

 

 

Mailing Address

 

City, State, Zip

 

 

 

 

 

 

Phone number:

 

Fax Number:

 

 

 

 

 

Status:

 

Appointment Date (mm/yyyy):

 

 

 

 

 

Can you admit / follow clients of your primary, secondary, other practice

locations?

Does Not Apply

 

Primary practice admits only

Secondary Practice admits only

Can admit to for all locations

B. PREVIOUS HOSPITAL AFFILIATIONS (Do not abbreviate)

 

 

 

 

 

 

 

 

 

Name of Admitting Hospital:

 

Department:

 

 

 

 

 

 

Mailing Address

 

City, State, Zip

 

 

 

 

 

Previous Status (active, provisional, courtesy, temporary, etc.):

From (mm/yyyy):

 

To (mm/yyyy):

 

 

 

 

 

 

Reason for Leaving:

 

 

 

 

 

 

 

 

 

Name of Admitting Hospital:

 

Department:

 

 

 

 

 

Mailing Address

 

City, State, Zip

 

 

 

 

Previous Status (active, provisional, courtesy, temporary, etc.):

From (mm/yyyy):

 

To (mm/yyyy):

 

 

 

 

 

 

Reason for Leaving:

 

 

 

 

 

 

 

 

 

Name of Admitting Hospital:

 

Department:

 

 

 

 

 

Mailing Address

 

City, State, Zip

 

 

 

 

Previous Status (active, provisional, courtesy, temporary, etc.):

From (mm/yyyy):

 

To (mm/yyyy):

 

 

 

 

 

 

Reason for Leaving:

 

 

 

 

 

C.CURRENT MILITARY AFFILIATIONS (Do not abbreviate) Please include Military Reserves

Name of Primary Base:

Division

 

 

 

Mailing Address

City, State , Zip

 

 

 

Phone number:

Fax Number:

 

 

 

Status (active, provisional, courtesy, temporary, etc.):

Appointment Date (mm/yyyy):

D. PREVIOUS MILITARY AFFILIATIONS (Do not abbreviate)

Name of Primary Base:

 

 

Division

 

 

 

 

Mailing Address

 

 

City, State , Zip

 

 

 

 

Phone number:

 

 

Fax Number:

 

 

 

Status (active, provisional, courtesy, temporary, etc.):

 

Appointment Date (mm/yyyy):

 

 

 

 

Washington Practitioner Application – January 2019

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Modification to the wording or format of the Washington Practitioner Application may invalidate the application.

E. APPLICATIONS IN PROCESS (Do not abbreviate)

Hospital/Institution:

Phone Number/Fax Number:

Date Application Submitted:

 

 

 

 

Mailing Address:

City:

State:

Zip Code:

 

 

 

 

Hospital/Institution:

Phone Number/Fax Number:

Date Application

Submitted(mm/yyyy)

 

 

 

 

Mailing Address:

City:

State:

Zip Code:

 

 

 

 

17. WORK HISTORY (Do not abbreviate)

Chronologically list all work history activities since completion of professional training (use extra sheets if necessary). This information must be complete. Curriculum vitae is not sufficient.

Name of Practice / Employer:

Contact Name:

 

 

Telephone Number:

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

Reason for Leaving:

Email Address

 

 

Fax Number:

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

Mailing Address

City:

State:

Zip:

From (mm/yyyy)

 

To (mm/yyyy)

 

 

 

 

 

 

 

Name of Practice / Employer:

Contact Name:

 

 

Telephone Number:

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

Reason for Leaving:

Email Address

 

 

Fax Number:

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

Mailing Address:

City:

State:

Zip Code:

From (mm/yyyy):

 

To (mm/yyyy):

 

 

 

 

 

 

 

Name of Practice / Employer:

Contact Name:

 

 

Telephone Number:

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

Reason for Leaving:

Email Address

 

 

Fax Number:

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

Mailing Address:

City:

State:

Zip Code:

From (mm/yyyy):

 

To (mm/yyyy):

 

 

 

 

 

 

 

 

18. GAPS IN HISTORY. Please account for all gaps between dates of medical/professional school graduation to present not covered elsewhere within this application. Include dates, activity and names where applicable:

From (mm/yyyy): To (mm/yyyy):

19. PEER REFERENCES

List at least three professional references, from your specialty area, not including relatives, who have worked with you in the past two years. References must be from individuals who, through recent observation, are directly familiar with your work and can attest to your clinical competence in your specialty area. If you have been out of residency or fellowship for a period of less than three years, one reference must be from the Program Director. Allied Health Providers must provide at least one reference from their same discipline.

 

Name of Reference:

Title and Specialty:

 

E-mail Address:

 

 

 

 

 

 

 

 

 

Mailing Address:

City:

 

 

State:

Zip Code:

 

 

 

 

 

 

 

Telephone Number:

Fax Number:

 

Cell Phone Number: (Optional)

 

(

)

(

)

 

(

)

 

 

 

 

 

 

 

 

Washington Practitioner Application – January 2019

Page 8 of 13

- 8 -

 

 

 

Modification to the wording or format of the Washington Practitioner Application may invalidate the application.

Name of Reference:

Title and Specialty:

E-mail Address:

 

 

 

 

 

 

 

Mailing Address:

City:

 

State:

Zip Code:

 

 

 

 

 

Telephone Number:

Fax Number:

Cell Phone Number:

(Optional)

(

)

(

)

(

)

 

 

Name of Reference:

Title and Specialty:

E-mail Address:

 

 

 

 

 

 

 

Mailing Address:

City:

 

State:

 

Zip Code:

 

 

 

 

Telephone Number:

Fax Number:

Cell Phone Number: (Optional)

(

)

(

)

(

)

 

 

20.PROFESSIONAL AFFILIATIONS (Do not abbreviate)

Please List Membership In All Professional Societies

 

 

 

 

 

 

 

 

 

Complete Name of Society:

 

 

 

 

Date Joined

 

 

Current Member

 

 

 

 

 

/

/

.

 

YES

NO

 

 

 

 

 

/

/

.

 

YES

NO

21. PROFESSIONAL LIABILITY (Do not abbreviate)

 

 

 

 

 

 

 

 

 

A. Current Insurance Carrier:

 

 

 

 

Policy Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

City:

 

 

 

State:

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

Phone Number:

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Per claim amount:

$

Aggregate amount:

$

 

 

Date Began (mm/yyyy):

 

Expiration Date

 

 

 

 

 

 

 

 

 

 

 

(mm/yyyy):

 

 

 

 

 

 

 

 

B. PREVIOUS PROFESSIONAL LIABILITY

CARRIERS WITHIN THE LAST TEN YEARS (Do not abbreviate)

 

(Attach Additional Sheet if Necessary)

 

 

 

 

 

 

 

 

 

 

Name of Carrier:

 

 

 

 

 

Policy Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

City:

 

 

 

State:

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

Phone Number:

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Per claim amount:

$

Aggregate amount:

$

 

 

Date Began (mm/yyyy):

 

Expiration Date

 

 

 

 

 

 

 

 

 

 

 

(mm/yyyy):

 

Name of Carrier:

 

 

 

 

 

Policy Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

City:

 

 

 

State:

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

Phone Number:

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Per claim amount:

$

Aggregate amount:

$

 

 

Date Began (mm/yyyy):

 

Expiration Date

 

 

 

 

 

 

 

 

 

 

 

(mm/yyyy):

 

Name of Carrier:

 

 

 

 

 

Policy Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

City:

 

 

 

State:

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

Phone Number:

 

 

 

 

 

Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Per claim amount:

$

Aggregate amount:

$

 

 

Date Began (mm/yyyy):

 

Expiration Date

 

 

 

 

 

 

 

 

 

 

 

(mm/yyyy):

 

Washington Practitioner Application – January 2019

Page 9 of 13

 

- 9 -

 

 

 

 

 

 

Modification to the wording or format of the Washington Practitioner Application may invalidate the application.

Name of Carrier:

 

 

 

Policy Number:

 

 

 

 

 

 

 

Mailing Address:

 

City:

 

State:

Zip Code:

 

 

 

 

 

 

Phone Number:

 

 

 

Fax Number:

 

 

 

 

 

 

 

Per claim amount:

$

Aggregate amount:

$

Date Began (mm/yyyy):

Expiration Date

 

 

 

 

 

(mm/yyyy):

Name of Carrier:

 

 

 

Policy Number:

 

 

 

 

 

 

 

Mailing Address:

 

City:

 

State:

Zip Code:

 

 

 

 

 

 

Phone Number:

 

 

 

Fax Number:

 

 

 

 

 

 

 

Per claim amount:

$

Aggregate amount:

$

Date Began (mm/yyyy):

Expiration Date

 

 

 

 

 

(mm/yyyy):

Name of Carrier:

 

 

 

Policy Number:

 

 

 

 

 

 

 

Mailing Address:

 

City:

 

State:

Zip Code:

 

 

 

 

 

 

Phone Number:

 

 

 

Fax Number:

 

 

 

 

 

 

 

Per claim amount:

$

Aggregate amount:

$

Date Began (mm/yyyy):

Expiration Date

 

 

 

 

 

(mm/yyyy):

Name of Carrier:

 

 

 

Policy Number:

 

 

 

 

 

 

 

Mailing Address:

 

City:

 

State:

Zip Code:

 

 

 

 

 

 

Phone Number:

 

 

 

Fax Number:

 

 

 

 

 

 

 

Per claim amount:

$

Aggregate amount:

$

Date Began (mm/yyyy):

Expiration Date

 

 

 

 

 

(mm/yyyy):

Washington Practitioner Application – January 2019

Page 10 of 13

- 10 -

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