Medical Assistant Certified or Interim Application Packet

DOH 651-015 September 2021

Medical Assistant-Certied or Interim Application

Packet

Contents:

1. 651-015 ......Contents List/SSN Information/Mailing Information ...................1 page

2. 651-016 ......Application Instructions Checklist.............................................2 pages

3. 651-017 ......Credentialing Requirements.....................................................3 pages

4. 651-018 ......Medical Assistant-Certied or Interim Application ....................5 pages

5. RCW/WAC and Online Website Links ............................................................1 page

Important Social Security Number Information:

If you have a Social Security Number, the law requires you to disclose it on your

application for a professional or occupational license. 42 U.S.C. § 666(a)(13); RCW

26.23.150. It will be used under the state’s child support enforcement program to locate

individuals for purposes of establishing paternity and establishing, modifying, and

enforcing support obligations. You are not required to have or obtain a Social Security

Number to apply for or obtain a license from the Department of Health. If you do not

have a Social Security Number, you are still eligible to apply for and obtain a credential

if you meet the requirements. Please see the Declaration of No Social Security Number

Form. Please call the Customer Service Center at 360-236-4700 if you have questions.

In order to process your request:

Mail your application with initial

documentation and your check Send other documents not sent with

or money order payable to: initial application to:

Department of Health Medical Assistant Credentialing

P.O. Box 1099 P.O. Box 47877

Olympia, WA 98507-1099 Olympia, WA 98504-7877

360-236-4700

To request this document in another format, call 1-800-525-0127. Deaf or hard of

hearing customers, please call 711 (Washington Relay) or email civil.rights@doh.

wa.gov.

This page intentionally left blank.

DOH 651-016 September 2023 Page 1 of 3

Important background check information: Washington State law authorizes the

Department of Health to obtain ngerprint-based background checks for licensing

purposes. This check 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 criminal record in Washington State. This would be at your own expense.

All information should be printed clearly in blue or black ink. It is your responsibility to

submit the required forms.

F Application Fee: (This fee is non-refundable). You can check the online

fee page for current fees.

F Check all that apply:

F Medical Assistant-Certied F Interim Certication

F Check if either apply:

Request for Military Training and Experience Evaluation

Spouse or Registered Domestic Partner of Military Personnel

F 1. Demographic Information:

Social Security Number: You must list your social security number on your

application. You are not required to have or obtain a Social Security Number

to apply for or obtain a license from the Department of Health. Please see the

Declaration of No Social Security Number Form. Please call the Customer Service

Center at 360-236-4700 if you do not have one.

National Provider Identier Number (NPI): The National Provider Identier (NPI)

is a standard unique identier for health care professionals available from the

Federal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric

identier. If you have a NPI number, provide this on your application.

Legal Name: List your full name: rst, middle, and last.

Denition of Legal Name: “Legal name” is the name appearing on your ocial

certicate of birth or, if your name has changed since birth, on an ocial marriage

certicate or an order by a court. The court must have legal authority to change

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 application may be denied.

Birth date: Provide the month, day, and year you were born.

Address: List the address we should use to send any information about your

certication. Be sure to include the city, state, zip code, county, and country. This

will be your permanent address with Department of Health until we have been

notied of a change, See WAC 246-12-310.

Phone, Fax and Cell Numbers: Enter your phone, fax and cell numbers, if you

have them.

Email: Enter your email address, if you have one.

Other Name(s): Indicate whether you are known or have been known under any

other names. If you have a name change, you must notify the Department of Health

in writing. You must include proof of this change. See WAC 246-12-300.

Application Instruction Checklist

DOH 651-016 September 2023 Page 2 of 3

F 2. Personal Data Questions:

All applicants must answer the same personal data questions. They are focused on

your tness to practice the essential skills of this profession.

If you answer “yes” to any questions in this section, you must provide an

appropriate explanation. You must provide the documentation listed in the note

after the questions. If you do not provide this, your application is incomplete and it

will not be considered.

• Question 5 includes misdemeanors, gross misdemeanors and felonies. You

do not have to answer yes if you have been cited for trac infractions. You

can obtain copies of court records through the county courthouse where the

conviction, plea, deferred sentence, or suspended sentence was entered.

• If you have been granted certicate(s) of restoration of opportunity, please

provide a certied copy of each certicate.

• Another jurisdiction means any other country, state, federal territory, or military

authority.

F 3. Training and Education:

List in date order your training and education. Attach additional pages if you need

more space.

F 4. Experience:

List in date order your professional work experience and practice. Attach additional

pages if you need more space.

F 5. National Certication or Examination:

You must pass a medical assistant certication examination within ve years prior

to submitting your initial application for medical assistant-certied, or currently hold

a national medical assistant certication with a national examination organization

approved by the secretary. Ocial scores or national certication must be sent

directly from the examination body directly to the Department of Health.

F 6. Other License, Certication, or Registration:

List all states, including Washington, where credentials are or were held. Attach

additional completed pages if you need more space. A Credential Verication

form may be sent to each state or jurisdiction that you have listed, requesting that

they complete and submit the form directly to the Department of Health.

F 7. Qualications and Training Attestation:

You must meet the Qualication and Training Requirements. You must sign and

date this as proof of completion.

F 8. Applicant Attestation and Signature:

You must sign and date this for us to process the application.

For Spouses and Registered Domestic Partners of Military

Personnel Being Transferred or Stationed in Washington:

Under state law, if you are the spouse or state-registered domestic partner of a

servicemember of any branch of the U.S. Military, to include Guard or Reserve, and

are applying for a health care professional credential in this state, you may be eligible

to have the processing of your application expedited to receive your credential more

quickly.

Documents to submit with your application should include the following:

• A copy of your spouse’s or registered domestic partner’s military transfer orders

to Washington State.

• One of the following:

- A copy of your marriage certicate to show proof of marriage; or

- A copy of a state’s declaration or registration showing you are in a state

registered domestic partnership with a member of the U.S. military.

For Current and Former Servicemembers Requesting

Evaluation of Military Training and Experience

Under state law, your military education, training, and experience may count towards

attaining certain civilian health care profession credentials in Washington State.

Submitted information will be reviewed by the Department of Health to determine

substantial equivalency for meeting the credentialing requirements in this state.

Documents to submit with your health care professional credential application should

include the following:

• If applicable, a copy of your DD214 Certicate of Release or Discharge from

Active Duty, Member-4 or service 2 copy, or NGB-22 for National Guard.

Please note:

- A copy of your DD214 can be downloaded from the EBenets website.

- You can request a replacement copy of your NGB-22 on the

National Archives website.

• Ocial Joint Service Transcript (JST) or Community College of the Air

Force(CCAF) Transcripts.

Please note:

- JST can be sent electronically by visiting the JST website and selecting

Washington State Department of Health.

- CCAF transcripts cannot be sent electronically. See the CCAF website for

transcript information.

• Verication of Military Experience and Training (VMET) or DD Form 2586. See

the DoDTAP website.

• If applicable, application for the Evaluation of Learning Experiences During

Military Service (DD Form 295). See the Military Resources website.

DOH 651-016 September 2023 Page 3 of 3

This page intentionally left blank.

Credentialing Requirements

Thank you for applying to become a medical assistant-certied in Washington State. In

order to qualify for certication, you must complete the following.

F Complete and submit the application, with an original signature, date, and fee.

F Sign and date the application as proof of:

• Completion of high school education or its equivalent.

F Education and Training:

Successful completion of one of the following medical assistant training programs:

a. Post-secondary school or college program accredited by the Accrediting

Bureau of Health Education School (ABHES) or the Commission of

Accreditation of Allied Health Education Programs (CAAHEP); or

b. Post-secondary school or college accredited by a regional or national

accrediting organization approved through the U.S. Department of Education,

which includes a minimum of 720 clock hours of training in medical assisting

skills, including a clinical externship of no less than 160 hours; or

c. A registered apprenticeship program administered by a department of the

state of Washington unless the secretary determines that the apprenticeship

program training or experience is not substantially equivalent to the

standards of this state. The apprenticeship program shall ensure a participant

who successfully completes the program is eligible to take one or more

examinations identied in WAC 246-827-0200(2); or

d. The Secretary may also approve an applicant who submits documentation that

he or she completed post-secondary education with a minimum of 720 clock

hours of training in medical assisting skills. The documentation must include

proof of training in all of the duties identied in RCW.18.360.050(1) and a

clinical externship of no less than 160 hours.

e. The Secretary may approve an applicant who submits documentation that they

completed a career and technical education program approved by the oce

of the superintendent of public instruction with a minimum of 720 clock hours

of training in medical assisting skills. The documentation must include proof

of training in all of the duties identied in RCW.18.360.050(1) and a clinical

externship of no less than 160 hours.

DOH 651-017 September 2023 Page 1 of 3

f. Military training or experience satises the training or experience requirements

unless the secretary determines that the military training or experience is

not substantially equivalent to the standards of this state. Provide ocial

transcripts showing proof of your education, training, and experience.

F Ocial Transcripts: Please contact your school or college to request ocial

transcripts of your medical assistant training program to be sent directly to the

Department of Health.

F Experience:

List in date order your professional experience and practice from date of completion

from your medical assistant training program. Include the month/day/year. Attach

additional completed pages if you need more space.

F Examination:

Successfully pass a medical assistant certication examination, approved by the

Secretary, within the preceding ve years of submitting an initial application or

currently hold a national medical assistant certication with a national examining

organization approved by the Secretary. A medical assistant certication

examination approved by the Secretary means an examination that:

• Is oered by a medical assistant program that is accredited by the National

Commission for Certifying Agencies (NCCA); and

• Covers the clinical and administrative duties under RCW 18.360.050(1).

National examining organizations approved by the Secretary:

a. Certied Medical Assistant Examination through the American Association of

Medical Assistants (AAMA);

b. Registered Medical Assistant Certication Examination through American

Medical Technologists (AMT);

c. Clinical Medical Assistant Certication Examination through the National

Healthcareer Association (NHA);

d. National Certied Medical Assistant Examination through the National Center

for Competency Testing (NCCT); Or,

e. Clinical Medical Assistant Certication Examination through the American

Medical Certication Association (AMCA).

F Other licenses, certications, or registration: A Credential Verication form may be

sent to each state where you hold or have held a credential. The state will complete

its portion of the form and mail it directly to the Department of Health.

DOH 651-017 September 2023 Page 2 of 3

Interim Certication Requirements:

An interim certication may be issued under the following conditions:

a. A person who has met all the application requirements except passage of the

examination, may be issued an interim certication.

b. A person holding an interim certication possesses the full scope of practice of a

medical assistant-certied.

A person’s interim certication expires upon passage of the

examination and issuance of the medical assistant-certied credential or

after one year, whichever occurs rst.

c. A person cannot renew an interim certication.

d. A person is only eligible for an interim certication upon initial application.

Note: You may not practice as a medical assistant-certied without a valid

credential.

DOH 651-017 September 2023 Page 3 of 3

This page intentionally left blank.

DOH 651-018 September 2021 Page 1 of 5

Revenue: 0252625081

Date

Stamp

Here

Name First Middle Last

Note: The mailing and email addresses you provide will be your addresses of record. It is your

responsibility to maintain current contact information on le with the department.

Country

Will documents be received in another name? F Yes F No

If yes, list name(s):

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)? F Yes F No

If yes, list name(s):

Country

Mailing address if dierent from above address of record

City State Zip Code County

Birth date (mm/dd/yyyy)

1. Demographic Information

Medical Assistant-Certied or Interim Application

Please handwrite clearly in ink. It is the responsibility of the applicant to submit all supporting documentation.

Failure to do so may result in a delay in processing your application.

Check all that apply: F Medical Assistant-Certied F Interim Certication

Social Security Number (SSN)

(If you do not have a SSN, see instructions)

F Male F Female

F Prefer Not to Answer

F X

National Provider Identier Number (NPI)

(Enter 10 digit number)

Select if either apply: F Request for Military Training and Experience Evaluation

F Spouse or Registered Domestic Partner of Military Personnel

Medical Assistant Credentialing

P.O. Box 1099

Olympia, WA 98507-1099

1. Do you have a medical condition which in any way impairs or limits your ability to practice your

profession with reasonable skill and safety? If yes, please attach explanation. ........................................ F F

“Medical Condition” includes physiological, mental or psychological conditions or

disorders, such as, but not limited to orthopedic, visual, speech, and hearing impairments,

cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes,

intellectual disabilities, emotional or mental illness, specic learning disabilities, HIV disease,

tuberculosis, drug addiction, and alcoholism.

If you answered yes to question 1, explain:

1a. How your treatment has reduced or eliminated the limitations caused by your medical condition.

1b. How your eld of practice, the setting or manner of practice has reduced or eliminated the

limitations caused by your medical condition.

Note: If you answered “yes” to question 1, the licensing authority will assess the nature,

severity, and the duration of the risks associated with the ongoing medical condition

and the ongoing treatment to determine whether your license should be restricted,

conditions imposed, or no license issued.

The licensing authority may require you to undergo one or more mental, physical or

psychological examination(s). This would be at your own expense. By submitting this

application, you give consent to such an examination(s). You also agree the

examination report(s) may be provided to the licensing authority. You waive all claims

based on condentiality or privileged communication. If you do not submit to a

required examination(s) or provide the report(s) to the licensing authority, your

application may be denied.

2. Do you currently use chemical substance(s) in any way which impair or limit your ability to

practice your profession with reasonable skill and safety? If yes, please explain. ....................................F F

“Currently” means within the past two years.

“Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally.

3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or

frotteurism? ................................................................................................................................................F F

4. Are you currently engaged in the illegal use of controlled substances? .................................................... F F

“Currently” means within the past two years.

Illegal use of controlled substances is the use of controlled substances (e.g., heroin, cocaine)

not obtained legally or taken according to the directions of a licensed health care practitioner.

Note: If you answer “yes” to any of the remaining questions, provide an explanation and

certied copies of all judgments, decisions, orders, agreements and surrenders. The

department does criminal background checks on all applicants.

5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had

prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? ....F F

Note: If you answered “yes” to question 5, you must send certied copies of all court

documents related to your criminal history with your application. If you do not

provide the documents, your application is incomplete and will not be considered.

If you have been granted certicate(s) of restoration of opportunity, please provide a certied

copy of each certicate.

To protect the public, the department considers criminal history. A criminal history

may not automatically bar you from obtaining a credential. However, failure to report

criminal history may result in extra cost to you and the application may be delayed

or denied.

DOH 651-018 September 2021 Page 2 of 5

2. Personal Data Questions

Yes No

DOH 651-018 September 2021 Page 3 of 5

2. Personal Data Questions (Cont.)

Yes No

6. Have you ever been found in any civil, administrative or criminal proceeding to have:

a. Possessed, used, prescribed for use, or distributed controlled substances or legend

drugs in any way other than for legitimate or therapeutic purposes? ..................................................F F

b. Diverted controlled substances or legend drugs?................................................................................F F

c. Violated any drug law? ........................................................................................................................F F

d. Prescribed controlled substances for yourself? ...................................................................................F F

7. Have you ever been found in any proceeding to have violated any state or federal law or rule

regulating the practice of a health care profession? If “yes”, please attach an explanation and

provide copies of all judgments, decisions, and agreements? . ................................................................F F

8. Have you ever had any license, certicate, registration or other privilege to practice a health care

profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? ...............F F

9. Have you ever surrendered a credential like those listed in number 8, in connection with or to

avoid action by a state, federal, or foreign authority? ................................................................................ F F

10. Have you ever been named in any civil suit or suered any civil judgment for incompetence,

negligence, or malpractice in connection with the practice of a health care profession? ..........................F F

11. Have you ever been disqualied from working with vulnerable persons by the Department

of Social and Health Services (DSHS)? ................................................................................................. F F

3. Training and Education

List in date order your training and education. Attach additional pages if you need more space.

Full Name, City and State/Schools Attended Degree Earned

Entrance Date Ending Date

Attendance

DOH 651-018 September 2021 Page 4 of 5

Credential

6. Other License, Certication, or Registration

List all states, including Washington, where you hold or have held a credential.

State/Jurisdiction Credential Type

Method of Licensure

Year Issued Number

Exam Endorse

(mm/dd/yy)

From

Type of Experience or Specialty

4. Experience

List in date order your professional work experience and practice. Attach additional pages if you need more space.

Name and Location of Institution

Grandparented

(mm/dd/yy)

5. Examination

Have you taken and passed one of the following exams within the last ve years? F Yes F No

Do you currently hold a national certication with one of the following organizations? F Yes F No

Please answer Yes or No and select all that apply:

F Certied medical assistant examination through American Association of Medical Assistants (AAMA)