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.
Question | Answer |
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Form Name | Wa Practitioner Application |
Form Length | 13 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 3 min 15 sec |
Other names | how to washington practitioner application, provider washington practitioner application, washington state practitioner applicatio, application washington state practitioner |
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:
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Birth Date: (mm/dd/yyyy) |
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Citizenship: |
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Social Security Number: |
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Languages Fluently |
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Have you ever voluntarily |
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NPI: |
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Medicare Number: (WA) |
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Medicaid (DSHS) Number(s): |
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Specialty primarily practicing: |
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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 |
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CHECK ALL THAT APPLY |
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Effective Date at PRIMARY Practice location (MM/YY) __________ |
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Practice Setting |
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Clinic/Group |
Solo Practice |
Home Based |
Hospital Based |
Primary Care Site |
Urgent Care |
Other |
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Practitioner Profile |
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PCP |
Specialist |
Check if you are both PCP & OB OB in your practice |
Yes |
No |
Deliveries |
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No |
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Name of Practice / Affiliation or Clinic Name: |
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Primary Office Street Address: |
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State: |
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Patient Appointment Telephone Number: |
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Mailing Address: (if different from above) |
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Billing Address: (if different from above) |
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Practice Website |
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Office Manager / Administrator Name: |
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Administration Telephone Number: |
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Fax Number: |
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Credentialing Contact (if different from above): |
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Name Affiliated with Tax ID Number: |
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Federal Tax ID Number: |
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Is the office wheelchair accessible? |
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Office Hours |
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Monday: ________________________ |
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Are you accepting new patients? |
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Have you limited your practice in any way (e.g. 18 years or older?) |
Tuesday: ________________________ |
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Wednesday: ______________________ |
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Thursday: ________________________ |
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Do you currently supervise ARNP’s or PA’s? |
Yes |
No |
Saturday: ________________________ |
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If yes, please provide the name and specialty below: |
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Sunday:__________________________ |
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Do you provide 24 hour coverage? |
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advice and care after hours: |
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A. Hospital Inpatient Coverage Plan (for those without admitting privileges) |
Does Not Apply |
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Name of Admitting Physician/Practice/Clinic/Group: |
Hospital Where privileged: |
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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 |
Page 2 of 13 |
- 2 - |
Modification to the wording or format of the Washington Practitioner Application may invalidate the application.
Effective Date at SECONDARY Practice location (MM/YYYY) |
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CHECK ALL THAT APPLY |
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Practice Setting |
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Clinic/Group |
Solo Practice |
Home Based |
Hospital Based |
Primary Care Site |
Urgent Care |
Other |
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Practitioner Profile |
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PCP |
Specialist |
Check if you are both PCP & OB OB in your practice |
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Yes |
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Deliveries |
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No |
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Name of Secondary Practice / Affiliation or Clinic Name: |
Department Name (if hospital based): |
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Primary Office Street Address: |
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City: |
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State: |
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Zip Code: |
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Org. NPI# |
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Patient Appointment Telephone Number: |
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Mailing Address: (if different from above) |
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Billing Address: (if different from above) |
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Practice Website |
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Office Manager / Administrator Name: |
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Administration Telephone Number: |
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Fax Number: |
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Credentialing Contact (if different from above): |
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Telephone Number: |
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Fax Number: |
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Name Affiliated with Tax ID Number: |
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Federal Tax ID Number: |
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Is the office wheelchair accessible? |
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Office Hours |
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Monday: ________________________ |
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Are you accepting new patients? |
Yes |
No |
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Have you limited your practice in any way (e.g. 18 years or older?) |
Tuesday: ________________________ |
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Wednesday: ______________________ |
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Thursday: ________________________ |
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Friday: __________________________ |
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Do you currently supervise ARNP’s or PA’s? |
Yes |
No |
Saturday: ________________________ |
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If yes, please provide the name and specialty below: |
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Sunday:__________________________ |
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_________________________________________________________ |
Do you provide 24 hour coverage? |
Yes |
No |
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If no, please explain how your patients obtain |
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Please list languages fluently spoken by office staff: |
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advice and care after hours: |
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A.Hospital Inpatient Coverage Plan (for those without admitting privileges)
Does Not Apply
Name of Admitting Physician/Practice/Clinic/Group:
Hospital Where privileged:
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Does Not Apply |
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Provider Name, Degree |
Specialty |
Address |
Phone Number |
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Attach a list of additional covering practitioners if needed
Washington Practitioner Application – January 2019 |
Page 3 of 13 |
- 3 - |
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: |
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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: |
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ECFMG Number (applicable to foreign medical graduates): |
Date Issued: |
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5.ALL OTHER PROFESSIONAL LICENSES, REGISTRATIONS AND CERTIFICATIONS
State: |
Lic/Reg/Cert Number: |
Date Issued |
Exp. Date |
Yr. Relinquish |
Reason: |
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State: |
Lic/Reg/Cert Number: |
Date Issued |
Exp. Date |
Yr. Relinquish |
Reason: |
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State: |
Lic/Reg/Cert Number: |
Date Issued |
Exp. Date |
Yr. Relinquish |
Reason: |
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6. UNDERGRADUATE EDUCATION (Do not abbreviate) |
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Biology) |
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Mailing Address: |
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College or University Name: |
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specific, e.g. BS |
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Biology) |
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Mailing Address: |
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7. MASTER DEGREE PROGRAM OR POST GRADUATE EDUCATION |
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Dates Attended (mm/yyyy - mm/yyyy): |
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Faculty Director: |
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Degree: |
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8.MEDICAL/PROFESSIONAL EDUCATION (Do not abbreviate)
Medical/Professional School: |
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Start Date: |
Graduation Date |
Degree Received |
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Medical/Professional School: |
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Graduation Date |
Degree Received |
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Washington Practitioner Application – January 2019 |
Page 4 of 13 |
- 4 - |
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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) |
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Does Not Apply |
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Institution: |
Phone Number: |
Fax Number: |
Program Director: |
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Mailing Address: |
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Zip Code: |
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Type of Internship: |
Specialty: |
From (mm/yyyy): |
To (mm/yyyy): |
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10. |
RESIDENCIES |
(Attach Additional Sheet if Necessary) |
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Does Not Apply |
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Type of Residency: |
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Did you successfully complete the program? |
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Institution: |
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Type of Residency: |
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Did you successfully complete the program? |
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11. |
FELLOWSHIPS |
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(Attach Additional Sheet if Necessary) |
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Does Not Apply |
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Fax Number: |
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Program Director: |
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Course of Study: |
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Did you successfully complete the program? |
Yes |
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Institution: |
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Phone Number: |
Fax Number: |
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Program Director: |
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Course of Study: |
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From (mm/yyyy): |
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To (mm/yyyy): |
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Did you successfully complete the program? |
Yes |
No (If "No", please explain on separate sheet.) |
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12. |
PRECEPTORSHIP |
(Attach Additional Sheet if Necessary) |
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Does Not Apply |
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Institution: |
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( ) |
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Dates Attended (mm/yyyy - mm/yyyy): |
Training: |
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Washington Practitioner Application – January 2019 |
Page 5 of 13 |
- 5 - |
Modification to the wording or format of the Washington Practitioner Application may invalidate the application.
13. FACULTY/TEACHING APPOINTMENTS (Attach Additional Sheet if Necessary) |
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Does Not Apply |
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Institution: |
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Telephone Number |
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Address |
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( |
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( ) |
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Dates Attended (mm/yyyy - mm/yyyy): |
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Position: |
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Faculty Director: |
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( |
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14. |
BOARD CERTIFICATION |
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Does Not Apply |
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Are you board or otherwise professionally certified? |
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Yes If "Yes", please complete |
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No If "No", describe your intent for certification, if any, and dates of testing for |
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below: |
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Certification on separate sheet. |
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Date Recertified |
Expiration Date |
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Issuing Board/Entity and State Issued |
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Specialty |
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Date Certified |
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(if any) |
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Have you applied for certification other than those indicated above? |
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Yes |
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No |
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If so, list certification and date: |
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Certification number if applicable: |
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If you participate in a specialty which does not have board certification, please indicate specialty: |
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15. OTHER CERTIFICATIONS ACLS, BLS, ATLS, PALS, NALS (e.g., Fluoroscopy, Radiography, etc.) |
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(Attach Certificate if Applicable) |
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Type: |
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Number: |
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Expiration Date: |
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Type: |
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Number: |
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Expiration Date: |
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16. |
HOSPITAL, MILITARY, & OTHER INSTITUTIONAL AFFILIATIONS |
Does Not Apply |
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Please list in reverse chronological order (with the current affiliation(s) first) all institutions where you (A) Current Hospital |
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affiliation, (B) Previous Hospital Affiliations, (C) Current Military Affiliation, (D) Previous Military Affiliations (E) Applications in |
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process This includes hospitals, surgery centers, institutions, corporations, military assignments, or government agencies. If |
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more space is needed, attach additional sheet(s). List only affiliations here, list employment in section XVII, Work History. |
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A. CURRENT HOSPITAL AFFILIATIONS (Do not abbreviate) |
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Name of Primary Admitting Hospital: |
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Department: |
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Mailing Address |
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City, State , Zip |
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Phone number: |
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Fax Number: |
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Status (active, provisional, courtesy, temporary, etc.): |
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Appointment Date (mm/yyyy): |
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Can you admit / follow clients of your primary, secondary, other practice |
locations? |
Does Not Apply |
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Primary practice admits only |
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Secondary Practice admits only |
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can admit to for all locations |
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Name of Secondary Admitting Hospital: |
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Department: |
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Mailing Address |
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City, State, Zip |
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Phone number: |
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Fax Number: |
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Status: |
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Appointment Date (mm/yyyy): |
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Can you admit / follow clients of your primary, secondary, other practice |
locations? |
Does Not Apply |
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Primary practice admits only |
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Secondary Practice admits only |
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Can admit to for all locations |
|||||||||||
Washington Practitioner Application – January 2019 |
|
Page 6 of 13 |
- 6 - |
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Modification to the wording or format of the Washington Practitioner Application may invalidate the application.
Name of Other Institutions: |
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Department: |
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Mailing Address |
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City, State, Zip |
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Phone number: |
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Fax Number: |
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Status: |
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Appointment Date (mm/yyyy): |
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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) |
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Name of Admitting Hospital: |
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Department: |
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Mailing Address |
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City, State, Zip |
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Previous Status (active, provisional, courtesy, temporary, etc.): |
From (mm/yyyy): |
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To (mm/yyyy): |
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Reason for Leaving: |
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Name of Admitting Hospital: |
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Department: |
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Mailing Address |
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City, State, Zip |
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Previous Status (active, provisional, courtesy, temporary, etc.): |
From (mm/yyyy): |
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To (mm/yyyy): |
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Reason for Leaving: |
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Name of Admitting Hospital: |
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Department: |
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Mailing Address |
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City, State, Zip |
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|||
Previous Status (active, provisional, courtesy, temporary, etc.): |
From (mm/yyyy): |
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To (mm/yyyy): |
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Reason for Leaving: |
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C.CURRENT MILITARY AFFILIATIONS (Do not abbreviate) Please include Military Reserves
Name of Primary Base: |
Division |
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Mailing Address |
City, State , Zip |
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Phone number: |
Fax Number: |
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Status (active, provisional, courtesy, temporary, etc.): |
Appointment Date (mm/yyyy): |
D. PREVIOUS MILITARY AFFILIATIONS (Do not abbreviate)
Name of Primary Base: |
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Division |
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Mailing Address |
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City, State , Zip |
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Phone number: |
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Fax Number: |
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Status (active, provisional, courtesy, temporary, etc.): |
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Appointment Date (mm/yyyy): |
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|
Washington Practitioner Application – January 2019 |
Page 7 of 13 |
- 7 - |
|
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: |
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Mailing Address: |
City: |
State: |
Zip Code: |
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Hospital/Institution: |
Phone Number/Fax Number: |
Date Application |
Submitted(mm/yyyy) |
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Mailing Address: |
City: |
State: |
Zip Code: |
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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: |
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Telephone Number: |
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( |
) |
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Reason for Leaving: |
Email Address |
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Fax Number: |
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||
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( |
) |
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Mailing Address |
City: |
State: |
Zip: |
From (mm/yyyy) |
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To (mm/yyyy) |
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Name of Practice / Employer: |
Contact Name: |
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Telephone Number: |
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( |
) |
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Reason for Leaving: |
Email Address |
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Fax Number: |
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( |
) |
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Mailing Address: |
City: |
State: |
Zip Code: |
From (mm/yyyy): |
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To (mm/yyyy): |
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Name of Practice / Employer: |
Contact Name: |
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Telephone Number: |
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( |
) |
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Reason for Leaving: |
Email Address |
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Fax Number: |
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( |
) |
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Mailing Address: |
City: |
State: |
Zip Code: |
From (mm/yyyy): |
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To (mm/yyyy): |
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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.
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Name of Reference: |
Title and Specialty: |
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Mailing Address: |
City: |
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State: |
Zip Code: |
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|||
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Telephone Number: |
Fax Number: |
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Cell Phone Number: (Optional) |
||||
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( |
) |
( |
) |
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( |
) |
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||
Washington Practitioner Application – January 2019 |
Page 8 of 13 |
- 8 - |
|
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|
Modification to the wording or format of the Washington Practitioner Application may invalidate the application.
Name of Reference: |
Title and Specialty: |
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Mailing Address: |
City: |
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State: |
Zip Code: |
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|||
Telephone Number: |
Fax Number: |
Cell Phone Number: |
(Optional) |
||||
( |
) |
( |
) |
( |
) |
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Name of Reference: |
Title and Specialty: |
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|||||
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Mailing Address: |
City: |
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State: |
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Zip Code: |
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||||
Telephone Number: |
Fax Number: |
Cell Phone Number: (Optional) |
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( |
) |
( |
) |
( |
) |
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|
20.PROFESSIONAL AFFILIATIONS (Do not abbreviate)
Please List Membership In All Professional Societies |
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Complete Name of Society: |
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Date Joined |
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Current Member |
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/ |
/ |
. |
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YES |
NO |
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/ |
/ |
. |
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YES |
NO |
|
21. PROFESSIONAL LIABILITY (Do not abbreviate) |
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A. Current Insurance Carrier: |
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Policy Number: |
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Mailing Address: |
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City: |
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State: |
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Zip Code: |
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Phone Number: |
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Fax Number: |
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Per claim amount: |
$ |
Aggregate amount: |
$ |
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Date Began (mm/yyyy): |
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Expiration Date |
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(mm/yyyy): |
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B. PREVIOUS PROFESSIONAL LIABILITY |
CARRIERS WITHIN THE LAST TEN YEARS (Do not abbreviate) |
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(Attach Additional Sheet if Necessary) |
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Name of Carrier: |
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Policy Number: |
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Mailing Address: |
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City: |
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State: |
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Zip Code: |
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Phone Number: |
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Fax Number: |
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||
Per claim amount: |
$ |
Aggregate amount: |
$ |
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Date Began (mm/yyyy): |
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Expiration Date |
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||
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(mm/yyyy): |
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Name of Carrier: |
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Policy Number: |
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Mailing Address: |
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City: |
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State: |
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Zip Code: |
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Phone Number: |
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Fax Number: |
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||
Per claim amount: |
$ |
Aggregate amount: |
$ |
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Date Began (mm/yyyy): |
|
Expiration Date |
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||
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(mm/yyyy): |
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Name of Carrier: |
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Policy Number: |
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Mailing Address: |
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City: |
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State: |
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Zip Code: |
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Phone Number: |
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Fax Number: |
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||
Per claim amount: |
$ |
Aggregate amount: |
$ |
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Date Began (mm/yyyy): |
|
Expiration Date |
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||
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(mm/yyyy): |
|
Washington Practitioner Application – January 2019 |
Page 9 of 13 |
|
- 9 - |
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|
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|
Modification to the wording or format of the Washington Practitioner Application may invalidate the application.
Name of Carrier: |
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Policy Number: |
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Mailing Address: |
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City: |
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State: |
Zip Code: |
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Phone Number: |
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Fax Number: |
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Per claim amount: |
$ |
Aggregate amount: |
$ |
Date Began (mm/yyyy): |
Expiration Date |
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(mm/yyyy): |
Name of Carrier: |
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Policy Number: |
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Mailing Address: |
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City: |
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State: |
Zip Code: |
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Phone Number: |
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Fax Number: |
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Per claim amount: |
$ |
Aggregate amount: |
$ |
Date Began (mm/yyyy): |
Expiration Date |
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(mm/yyyy): |
Name of Carrier: |
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Policy Number: |
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Mailing Address: |
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City: |
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State: |
Zip Code: |
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Phone Number: |
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Fax Number: |
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Per claim amount: |
$ |
Aggregate amount: |
$ |
Date Began (mm/yyyy): |
Expiration Date |
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(mm/yyyy): |
Name of Carrier: |
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Policy Number: |
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Mailing Address: |
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City: |
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State: |
Zip Code: |
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Phone Number: |
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Fax Number: |
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Per claim amount: |
$ |
Aggregate amount: |
$ |
Date Began (mm/yyyy): |
Expiration Date |
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(mm/yyyy): |
Washington Practitioner Application – January 2019 |
Page 10 of 13 |
- 10 - |
Modification to the wording or format of the Washington Practitioner Application may invalidate the application.