In Home Services License Application Packet 505052

User Manual: 505052

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In-Home Services License Application Packet
Contents:
1.

505-052.....Contents List / Mailing Information.................................................1 Page

2.

505-053.....Application Instructions Checklist................................................. 3 Pages

3.

505-109.....License Requirements...................................................................1 Page

4.

505-051.....In-Home Services Application...................................................... 5 Pages

5.

505-055.....Disclosure Statement.....................................................................1 Page

6.

RCW/WAC and Online Web Site Links............................................................1 Page

In order to process your request:
Mail your application with initial
documentation and your check			
or money order payable to:			
Department of Health				
PO Box 1099						
Olympia, WA 98507-1099				
			

Send other documents not sent
with initial application to:
In-Home Service Credentialing
PO Box 47877
Olympia, WA 98504-7877

			
							Contact us:
							360-236-4700

DOH 505-052 March 2013

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Application Instructions Checklist
When your application for In-Home Services Agency License is received by the
Department of Health (DOH), it will be reviewed and you will be notified in writing of any
outstanding documentation needed to complete the process.
All information should be typed or printed clearly in blue or black ink. It is your
responsibility to submit the correct required forms.
Indicate type of application—new, change of ownership, amended or renewal.
•

New—First time requesting an In-Home Service Agency license.

•

Change of Ownership—When name of legal owner/operator changes resulting
from the sale of a licensed In-Home Service Agency.

•

Amended—To request the addition of a Service Category (e.g. Home Care,
Hospice, Hospice Care Center, Home Health); add or eliminate Service(s),
change Accreditation information, add or eliminate a Service Area(s), change
Administrator, Clinical Director or Direct Supervisor information, add Other
Office Locations.

•

Renewal—To renew an existing In-Home Services License.

FF Check One: Please check your legal owner/operator business structure type
according to your Washington State Master Business License.
FF Application Fee: You can check the online fee page for current fees.
FF 1. Demographic Information:
Uniform Business Identifier Number (UBI #): Enter your Washington State UBI
#. All Washington State businesses must have UBI #s. City, county, and state
government departments also have UBI #s.
Federal ID Number (FEIN #): Enter your Federal ID Number, if the business has
been issued one.
Legal Owner/Operator Name: Enter the owner’s name as it appears on the
UBI/Master Business License.
Mailing Address: Enter the owner’s complete mailing address.
Phone and Fax: Enter the owner’s phone and fax numbers.
Email and Web Address: Enter the owner’s email and facility Web addresses, if
applicable.
Facility/Agency Name: Enter the doing business as name. Name used on
advertising, signs, and web sites.
Physical Address: Enter the facility’s physical street location including city, state,
zip code, and county.
Phone and Fax Numbers: Enter the agency’s phone and fax number.
Mailing Address: Enter the agency’s mailing address, if different than physical
address.
DOH 505-053 March 2013		

Page 1 of 3

FF 2. Facility Specific Information:
A.

Service Categories: Please check all in-home service categories that
apply.
Service Categories of Home Care, Home Health, and Hospice: Enter the
number of Full Time Equivalents (FTEs). To calculate FTEs, an example would
be, take your agency’s total labor hours for one year and divide that number by
2080.
Service Categories of Hospice Care Center: Enter the number of licensed
beds authorized by the Certificate of Need and Construction Review Services.

B.

Services Provided:
Home Care Services: Please check all that apply.
Home Health Services: Please check all that apply. You must choose at least
two home health services before you may provide home care services.
Hospice Services: Please check all that apply.
Hospice Care Center Services: Please check all that apply.

C.

Medicare Designation/Certification:
Please check if agency is Medicare certified to provide Home Health or
Hospice services. If check Yes, enter the corresponding six character provider
number(s). In Washington this provider number always begins with 50. If you
do not know your six character provider number, please contact your Medicare
Fiscal Intermediary.
AAA and/or DDD Contracts:
Check yes or no. If yes, please enter the contract dates, last monitoring survey
and the agency who conducted the monitoring survey.
Accreditation Information:
Agency 1 and 2: If your agency is accredited, please enter the name of the
accreditation agency, the accreditation effective date, expiration date, and
check the box for accreditation as a Home Health or Hospice agency.

D.

Service Areas:
Check the service counties and service categories in which you deliver care to
patients or clients. If you only deliver care in part of a county, attach a separate
sheet describing the service area within the county. For Medicare, check both
state counties you provide services in as well as those counties that were
authorized by Certificate of Need for Medicare.

FF 3. Key Individuals:
A.

Administrator:
Enter the administrators name, phone number, fax number, email address, and
hire date. This must be the same person identified on the Disclosure Statement
and Criminal History Background Check.
Direct Supervisor (Home Care Category):  Enter the supervisor’s name,
phone number, fax number, email address, and hire date. This must be the
same person identified on the Disclosure Statement and Criminal History
Background Check.

DOH 505-053 March 2013		

Page 2 of 3

Clinical Director (Home Health and/or Hospice Category): Enter the
director’s name, phone number, fax number, email address, and hire date. This
must be the same person identified on the Disclosure Statement and Criminal
History Background Check.
B.

Legal Owner Information:
List the names, titles, addresses, and phone numbers of the corporate officers,
LLC members, partners, individuals owning 10% or more of the agency. Attach
additional sheet, if necessary.

FF 4. Other Office Locations:
Other Office Locations:  
Enter the name, street address, mailing address, phone number, fax number, email
address, and on-site manager or supervisor name. Check the service categories
provided from this location. If there are more than two locations, please attach
additional sheets as needed. If this is an approved Medicare Branch Office, check
the box.
FF 5. Change of Ownership Information:
For the current and prospective legal owners, enter the name, phone number,
current license number, agency name, agency address, email address, and
effective date of ownership change. Current and prospective legal owners must
attest to the change in ownership by signing their names on the space provided
and indicate the date signed.
FF Signature:
Signature of legal owner or authorized representative.
Date signed.
Print name of legal owner or authorized representative.
Print title of legal owner or authorized representative.

Additional Information:
For more information on serving state funded DSHS clients, please contact your local
Area Agency on Aging (AAA) at 1800-422-3263 or the Division of Developmental
Disabilities (DDD) at 1800-562-3022.
DSHS can explain the requirements for contracting with them. Contracts are not
available to newly licensed home health agencies.
Contact the AAA or DDD before completing the Department of Health application packet
if you wish to also provide services to DSHS clients.
The Area Agency on Aging can be found at http://www.aasa.dshs.wa.gov/.

DOH 505-053 March 2013		

Page 3 of 3

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License Requirements

In order to process your request you must provide the
following:
FF Return completed application, along with the application fee.
FF Professional and Liability Insurance: Attach proof of the current professional and
liability insurance as per WAC 246-335-025.
FF Disclosure Statement : Attach a copy of the Disclosure Statement for the on-site
Administrator/Director, Director of Clinical Services (Home Health or Hospice), or
Supervisor of Direct Care Services (Home Care). Agencies must keep on file a
current Disclosure Statement for the Administrator, Director of Clinical Services
or Supervisor of Direct Care Services as stated in WAC 246-335-025 (1)(c) and
WAC 246-335-030 (3). Current copies must be dated within 3 months of the initial
application date.
FF Criminal History Background Check (CBC): Attach a copy of the current CBC of
the on-site Administrator, Director of Clinical Services (Home Health or Hospice),
or Supervisor of Direct Care Services (Home Care). Agencies must keep on file
a current CBC for the Administrator, Director of Clinical Services or Supervisor of
Direct Care Services as stated in WAC 246-335-025 (1)(c) and
WAC 246-335-030 (3). Current copies must be dated within 3 months of the initial
application date.
FF Copy of any and all current government issued business license(s) for each office
location which may include state, county or city licenses.
FF A description of how the agency will provide management and supervision of
services throughout the service area(s).

DOH 505-109 March 2013

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Date
Stamp
Here
Revenue: 0597632360

In-Home Services Agency License Application
This is for:

 New

 Change of Ownership

 Amended

 Renewal

Check One
	 Association
	 Corporation
	 Federal Government Agency
c For-Profit
	 Limited Liability Company
	 Limited Liability Partnership

	 Limited Partnership
	 Municipality (City)
	 Municipality (County)
	 Non-Profit Corporation
	 Partnership

	 Public Hospital District
	 Sole Proprietor
 State Government Agency
	 Tribal Government Agency
	 Trust

1. Demographic Information
UBI #

							

Federal Tax ID (FEIN) #

Legal Owner/Operator Name
Mailing Address
City 						

State

Zip Code

County

Phone (enter 10 digit #)					

Fax (enter 10 digit #)

Email Address			

Web Address:

				

Facility / Agency Name (Doing business as name. Name used on advertising, signs, and web sites)
Physical Address
City							

State

Facility Phone (enter 10 digit #)			

Zip Code		

County

Facility Fax (enter 10 digit #)

Mailing Address (If different than physical address)
City

					

State

Zip Code

County

For Office Use Only

License #___________________________________________ Issue Date ___________________________
DOH 505-051 March 2013

Page 1 of 6

2. Facility Specific Information
A. Check all service categories provided:
Service Category            # of FTE’s

Service Category                # of Beds

c Home Care

______

c Hospice Care Center

c Home Health

______

c Hospice

______

B. Check all services provided:
Home Care Services

c Personal Care
c Homemaker/Chore

 Respite Care
		

		

_______

 Transportation

Home Health Services - Choose a least two services provided

c Skilled Nursing
		c Respiratory Therapy		
 Home Health Aide			
c Medical Social Services		
c Durable Medical Equipment
c Occupational Therapy		
c Speech Therapy			
c Nutritional Counseling		

					

c Bereavement Counseling
c Physical Therapy			
 I.V. Services			
c Applied Behavior Analysis

In addition to those services listed above, you may select any of the following:
c Personal Care
c Homemaker/Chore

 Respite Care

Hospice Services

c Skilled Nursing			
 Home Health Aide			
c Physical Therapy			
c Occupational Therapy		
c Speech Therapy			
c Respiratory Therapy		
c Medical Social Services

Hospice Care Center Services
c Continuous Care			
c In-Patient Respite Care

		

 Transportation

					

c Durable Medical Equipment
 I.V. Services			
c Nutritional Counseling		
c Bereavement Counseling		
c Personal Care			
c Homemaker/Chore			








Respite Care
Volunteer
Spiritual Counseling		
Pallative Care
Symptom & Pain Mgmt.		
Pharmacy Services

c Routine Home Care		

 General In-Patient Care

C. Medicare, Medicaid, and Accreditation information:
Is agency currently Medicare certified? c Yes c No

Home Health Medicare Provider # ____________________ Hospice Medicare Provider #_____________________
Does the agency have a DSHS Medicaid contract? c Yes c No Secure Fax (enter 10 digit #) ________________

If yes, complete all the below AAA and/or DDD contracts that apply:
c DSHS Personal Care Program

Contract Dates
______to______

Last Monitoring Survey
____________________		

By Whom
________________

c DSHS Chore Services		

______to______

____________________		

________________

c DSHS Respite Program		

______to______

____________________		

________________

c DSHS / DDD			

______to______

____________________		

________________

c Other				

______to______

____________________		

________________

Name of Accreditation Agency #1

Name of Accreditation Agency #2

_________________________________

_________________________________

Effective Date______________________

Effective Date______________________

Expiration Date_____________________

Expiration Date_____________________

	 Home Health

	 Home Health

DOH 505-051 March 2013

	 Hospice

	 Hospice
Page 2 of 6

D. Requested Service Areas
Home
Care

State Home
Health

State
Hospice

State Hospice
Care Center

Medicare
Home
Health

Medicare
Hospice

Medicare
Hospice
Care Center

c Adams

c

c

c

c

c

c

c

c Asotin

c

c

c

c

c

c

c

c Benton

c

c

c

c

c

c

c

c Chelan

c

c

c

c

c

c

c

c Clallam

c

c

c

c

c

c

c

c Clark

c

c

c

c

c

c

c

c Columbia

c

c

c

c

c

c

c

c Cowlitz

c

c

c

c

c

c

c

c Douglas

c

c

c

c

c

c

c

c Ferry

c

c

c

c

c

c

c

c Franklin

c

c

c

c

c

c

c

c Garfield

c

c

c

c

c

c

c

c Grant

c

c

c

c

c

c

c

c Grays Harbor

c

c

c

c

c

c

c

c Island

c

c

c

c

c

c

c

c Jefferson

c

c

c

c

c

c

c

c King

c

c

c

c

c

c

c

c Kitsap

c

c

c

c

c

c

c

c Kittitas

c

c

c

c

c

c

c

c Klickitat

c

c

c

c

c

c

c

c Lewis

c

c

c

c

c

c

c

c Lincoln

c

c

c

c

c

c

c

c Mason

c

c

c

c

c

c

c

c Okanogan

c

c

c

c

c

c

c

c Pacific

c

c

c

c

c

c

c

c Pend Oreille

c

c

c

c

c

c

c

c Pierce

c

c

c

c

c

c

c

c SanJuan

c

c

c

c

c

c

c

c Skagit

c

c

c

c

c

c

c

c Skamania

c

c

c

c

c

c

c

c Snohomish

c

c

c

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c

c

c

c Spokane

c

c

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c

c Stevens

c

c

c

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c

c Thurston

c

c

c

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c

c Wahkiakum

c

c

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c

c

c

c

c Walla Walla

c

c

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c

c

c Whatcom

c

c

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c

c

c

c Whitman

c

c

c

c

c

c

c

c Yakima

c

c

c

c

c

c

c

County

DOH 505-051 March 2013

Page 3 of 6

3. Key Individuals

A. Complete all that apply:
Administrator Name
Phone (enter 10 digit #)

		

Fax (enter 10 digit #)

Email Address									

Hire Date

Direct Supervisor Name (Home Care)
Phone (enter 10 digit #)

		

Fax (enter 10 digit #)

Email Address									

Hire Date

Clinical Director Name (Home Health, Hospice)
Phone (enter 10 digit #)

		

Fax (enter 10 digit #)

Email Address									

Hire Date

B. Legal Owner Information–attach additional sheets as needed

List the names, titles, addresses, and phone numbers of the corporate officers, LLC members, partners, individuals
owning 10% or more of the agency.
Name				
		
Title

Mailing Address								
City							
Name				

State
		

Zip Code		

Phone (enter 10 digit #)

Title

Mailing Address								
City							
Name				

State
		

Zip Code		

Phone (enter 10 digit #)

Title

Mailing Address								
City							

DOH 505-051 March 2013

State

Zip Code		

Phone (enter 10 digit #)

Page 4 of 6

4. Other Office Locations - Attach additional completed pages if you need more space.
Office Name									

c Approved Medicare Branch Office

Physical Address
Mailing Address (if different from physical)
City 									 Zip Code		 County			
Phone (enter 10 digit #) 					

Fax (enter 10 digit #)			

Email Address
On-Site Manager or Supervisor
In-Home services categories provided from this location				
 Home Health		

 Home Care		

 Hospice

Office Name									

 Hospice Care Center
c Approved Medicare Branch Office

Physical Address
Mailing Address (if different from physical)
City 									 Zip Code		 County			
Phone (enter 10 digit #) 					

Fax (enter 10 digit #)			

Email Address
On-Site Manager or Supervisor
In-Home services categories provided from this location				
 Home Health		

 Home Care		

 Hospice

Office Name									

 Hospice Care Center
c Approved Medicare Branch Office

Physical Address
Mailing Address (if different from physical)
City 									 Zip Code		 County			
Phone (enter 10 digit #) 					

Fax (enter 10 digit #)			

Email Address
On-Site Manager or Supervisor
In-Home services categories provided from this location				
 Home Health		
DOH 505-051 March 2013

 Home Care		

 Hospice

 Hospice Care Center
Page 5 of 6

5. Change of Ownership Information
Name of Current Legal Owner: 				

Current Facility/Agency License Number:

Name of Current Facility/Agency:					
Effective Date of Ownership Change:

Current Owner Phone (enter 10 digit #):

Current Facility/Agency Physical Address:
Name of Prospective Legal Owner:				

Prospective Owner Phone (enter 10 digit #):		

Name of Prospective Facility/Agency:			

Prospective Owner Email Address:

Prospective Facility/Agency Physical Address:

_______________________________________________ ____________________________________________
Signature of current legal owner

Date

Signature of prospective legal owner

Date

_______________________________________________ ____________________________________________
Print name of current legal owner

Date

Print name of prospective legal owner

Date

Signature
I certify that I have received, read, understood, and agree to comply with state law and rule regulating this licensing
category. I also certify that the information herein submitted is true to the best of my knowledge and belief.

___________________________________________________________

______________________________________

___________________________________________________________

______________________________________

Signature of owner/authorized representative			

Print Name			

DOH 505-051 March 2013

Date

Print Title

Page 6 of 6

Disclosure Statement
I, ________________________________________________________________ have never been:
1.

Convicted of a crime against children or other persons.
Aggravated murder; first or second degree murder; first or second degree kidnapping; first,
second, third degree assault; first, second, or third degree assault of a child; first, second, or third
degree rape; first, second, or third degree rape of a child; first or second degree robbery; first
degree arson; first degree burglary; first or second degree manslaughter; first or second degree
extortion; indecent liberties; incest; vehicular homicide; first degree promotion prostitution;
communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of
minors; first or second degree criminal mistreatment; child abuse or neglect as defined in
RCW 26.44.020; first or second degree custodial interference; malicious harassment; first,
second, or third degree child molestation; first or second degree sexual misconduct with a
minor; patronizing a juvenile prostitute; child abandonment; promoting pornography; selling or
distributing erotic material to a minor; custodial assault; violation of child abuse restraining order;
child buying or selling; prostitution; felony indecent exposure; criminal abandonment; or any of
these crimes as they be rename in the future.

2.

Convicted of crimes relating to financial exploitation if the victim was a vulnerable adult.
A conviction for first, second, or third degree extortion; first, second, or third degree theft; first
or second degree robbery; forgery; or any of these crimes that may be renamed in the future.
A vulnerable adult is an adult who lacks the functional, mental, or physical ability to care for
themselves

3.

Convicted of crimes related to drugs;
A conviction of a crime to manufacture, deliver, or possession with intent to manufacture or
deliver a controlled substance.

4.

Found in any dependency action under RCW 13.34.040 to have sexually assaulted or
exploited any minor or to have physically abused any minor;

5.

Found by a court in a domestic relations proceeding under Title 26 RCW to have sexually
abused or exploited any minor or to have physically abused any minor;

6.

Found in any disciplinary board final decision to have sexually or physically abuse or
exploited any minor or developmentally disabled person or to have abused or financially
exploited any vulnerable adult;
Any final decision issued by a disciplining authority under RCW 18.130 or the secretary of the
department of health for the following businesses or professions: chiropractic, dentistry, dental
hygiene, massage, midwifery, naturopathy, osteopathic medicine and surgery, physical therapy,
physicians, practical nursing, registered nursing, and psychology.

7.

Found by a court in a protection proceeding under RCW. 74.34, to have abused or
financially exploited a vulnerable adult.
The illegal or improper use of a vulnerable adult or that adult’s resources for another person’s
profit or advantage.

Employee Signature __________________________________________ Date: ________________
Witness Signature ____________________________________________ Date: ________________
DOH 505-055 March 2013		

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RCW/WAC and Online Web Site Links

RCW/WAC Links
In-Home Services Laws............................................................................... RCW 70.127
In-Home Services Rules............................................................................. WAC 246-335

On-Line
In-Home Services Program.............................................................................. Web Page

		

RCW/WAC and Online Web Site Links March 2013



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History Instance ID             : xmp.iid:52F90DDC01BBE111B65FD91185EF61C6, xmp.iid:53F90DDC01BBE111B65FD91185EF61C6, xmp.iid:57F90DDC01BBE111B65FD91185EF61C6, xmp.iid:58F90DDC01BBE111B65FD91185EF61C6, xmp.iid:8CEF3AF894E1E111941CB8522BD57168, xmp.iid:9633DF353BE2E1118FCEE5E7A079B007, xmp.iid:9A33DF353BE2E1118FCEE5E7A079B007, xmp.iid:7B10AF3058E2E1118FCEE5E7A079B007, xmp.iid:7C10AF3058E2E1118FCEE5E7A079B007, xmp.iid:7EC1311C5AE2E1118FCEE5E7A079B007, xmp.iid:85C1311C5AE2E1118FCEE5E7A079B007, xmp.iid:3B39B39A6AE2E1118FCEE5E7A079B007, xmp.iid:9D5151AC6DE2E1118FCEE5E7A079B007, xmp.iid:9E0A0965F612E2118154D1A468EB7F06, xmp.iid:9F0A0965F612E2118154D1A468EB7F06, xmp.iid:1C79971D1C13E2118154D1A468EB7F06, xmp.iid:E44038F9B713E211AF338B42CEBC0EE8, xmp.iid:17B550F48414E2119508D8F4B905B7CD, xmp.iid:11D602498F14E21186AB9CDBAAD895EC, xmp.iid:4A34267B9114E21186AB9CDBAAD895EC, xmp.iid:5134267B9114E21186AB9CDBAAD895EC, xmp.iid:2449194A9614E21186AB9CDBAAD895EC, xmp.iid:BD2B2CF59B14E21186AB9CDBAAD895EC, xmp.iid:E304E9F22D1DE2118A74ACBB08CCFA86, xmp.iid:E404E9F22D1DE2118A74ACBB08CCFA86, xmp.iid:03CF47D6311DE2118A74ACBB08CCFA86, xmp.iid:9FBF0CC45433E211BFF0B9BD93FCCD97, xmp.iid:A6BF0CC45433E211BFF0B9BD93FCCD97, xmp.iid:BBF288D0823AE2119351ECA0CD591665, xmp.iid:C2F288D0823AE2119351ECA0CD591665, xmp.iid:3D4D7438833AE2119351ECA0CD591665, xmp.iid:E0FC1D1B084AE21184A7E37379C43C21, xmp.iid:5152B906134AE21184A7E37379C43C21, xmp.iid:CACF1E7C134AE21184A7E37379C43C21, xmp.iid:C513C9890B51E211A8BFD456CB1F79FA, xmp.iid:CC13C9890B51E211A8BFD456CB1F79FA, xmp.iid:E2D405E80B51E211A8BFD456CB1F79FA, xmp.iid:1820C3042A51E211A8BFD456CB1F79FA, xmp.iid:1F20C3042A51E211A8BFD456CB1F79FA, xmp.iid:2D2AFB94CC59E2119920BDAAE92B0094, xmp.iid:2E2AFB94CC59E2119920BDAAE92B0094, xmp.iid:352AFB94CC59E2119920BDAAE92B0094, xmp.iid:6736C3D6CE59E2118D1AD74A04130A76, xmp.iid:98B5B0D2CF59E2118D1AD74A04130A76, xmp.iid:05C1B2475E8AE21189398048699AC5B5, xmp.iid:C9F51A7D888AE21189398048699AC5B5, xmp.iid:D0F51A7D888AE21189398048699AC5B5, xmp.iid:3415DE80888AE21189398048699AC5B5, xmp.iid:3515DE80888AE21189398048699AC5B5, xmp.iid:F816697589E1E61182A0EE8FBAC19E70, xmp.iid:FF16697589E1E61182A0EE8FBAC19E70
History When                    : 2012:06:20 11:00:45-07:00, 2012:06:20 11:00:45-07:00, 2012:06:20 11:00:50-07:00, 2012:06:20 11:00:50-07:00, 2012:08:08 14:56:55-07:00, 2012:08:09 08:59:33-07:00, 2012:08:09 08:59:33-07:00, 2012:08:09 12:27-07:00, 2012:08:09 12:27-07:00, 2012:08:09 12:40:44-07:00, 2012:08:09 12:42:21-07:00, 2012:08:09 14:44:59-07:00, 2012:08:09 15:00:46-07:00, 2012:10:10 10:34:20-07:00, 2012:10:10 13:50:25-07:00, 2012:10:10 13:50:25-07:00, 2012:10:11 16:37:08-07:00, 2012:10:12 08:53:24-07:00, 2012:10:12 10:07:21-07:00, 2012:10:12 10:23:04-07:00, 2012:10:12 10:41:28-07:00, 2012:10:12 10:57:29-07:00, 2012:10:12 11:38:04-07:00, 2012:10:23 09:23:16-07:00, 2012:10:23 09:38:42-07:00, 2012:10:23 09:51:06-07:00, 2012:11:20 12:56:33-08:00, 2012:11:20 12:56:33-08:00, 2012:11:29 16:13:49-08:00, 2012:11:29 16:13:49-08:00, 2012:11:29 16:16:43-08:00, 2012:12:19 11:33:55-08:00, 2012:12:19 11:33:55-08:00, 2012:12:19 11:37:12-08:00, 2012:12:28 08:27:57-08:00, 2012:12:28 08:27:57-08:00, 2012:12:28 08:30:35-08:00, 2012:12:28 12:06:08-08:00, 2012:12:28 12:09:55-08:00, 2013:01:08 11:57:30-08:00, 2013:01:08 11:57:30-08:00, 2013:01:08 12:01:08-08:00, 2013:01:08 12:06:07-08:00, 2013:01:08 12:13:10-08:00, 2013:03:11 13:15:59-07:00, 2013:03:11 13:15:59-07:00, 2013:03:11 13:16:05-07:00, 2013:03:11 13:16:05-07:00, 2013:03:11 13:20:56-07:00, 2017:01:23 08:31:57-08:00, 2017:01:23 08:31:57-08:00
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History Changed                 : /;/metadata, /metadata, /;/metadata, /metadata, /;/metadata, /metadata, /;/metadata, /;/metadata, /metadata, /;/metadata, /;/metadata, /;/metadata, /;/metadata, /;/metadata, /metadata, /;/metadata, /;/metadata, /;/metadata, /;/metadata, /;/metadata, /;/metadata, /;/metadata, /;/metadata, /;/metadata, /;/metadata, /;/metadata, /metadata, /;/metadata, /metadata, /;/metadata, /;/metadata, /metadata, /;/metadata, /;/metadata, /metadata, /;/metadata, /;/metadata, /;/metadata, /;/metadata, /metadata, /, /;/metadata, /;/metadata, /;/metadata, /metadata, /;/metadata, /;/metadata, /metadata, /;/metadata, /metadata, /;/metadata
Format                          : application/pdf
Title                           : In-Home Services License Application Packet
Creator                         : Washington State Department of Health, Health Systems Quality Assurance, Health Professions and Facilities
Subject                         : In-Home Service, credential, license, application, packet, instructions, forms, form
Description                     : An application packet for in-home services to be licensed in the state of Washington
Startup Profile                 : Print
Doc Change Count                : 9009
Producer                        : Adobe PDF Library 9.9
Trapped                         : False
Page Count                      : 17

EXIF Metadata provided by EXIF.tools