Athletic Trainer Expired License Activation Application 644 007 644005
User Manual: 644-007
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Athletic Trainer Expired License Activation Application Packet Contents: 1. 644-005.....Contents List/SSN Information/Mailing Information........................1 page 2. 644-006.....Application Instructions Checklist..................................................2 pages 3. 644-007.....Athletic Trainer Expired License Activation Application.................3 pages 4. 644-008.....Out-of-State Credential Verification Form.....................................2 pages 5. RCW/WAC and Online Website Links...............................................................1 page Important Social Security Number Information: You are required by state and federal law to provide a social security number with your application. If you do not have a social security number at the time you send in this application, please read, complete, and return this form with your application. A U.S. Individual Taxpayer Identification Number (ITIN) or a Canadian Social Insurance Number (SIN) cannot be substituted. In order to process your request: Mail your application with initial documentation and your check or money order payable to: Send other documents not sent with initial application to: Department of Health P.O. Box 1099 Olympia, WA 98507-1099 Athletic Trainer Credentialing P.O. Box 47877 Olympia, WA 98504-7877 Contact us: 360-236-4700 DOH 644-005 June 2016 (This page intentionally left blank.) Application Instructions Checklist You will be notified in writing if more documentation is required. To ensure you have submitted the necessary fees and documentation, we encourage you to use the following checklist: FF Pay Late Renewal Penalty Fee. FF Pay Current Renewal Fee. FF Pay Expired License Reactivation Fee. All fees are non-refundable. You can check the fee page for current fees. FF 1. Demographic Information. Social Security Number: You must list your social security number on your application. Please call the Customer Service Center at 360-236-4700 if you do not have one. National Provider Identifier Number (NPI): The National Provider Identifier (NPI) is a standard unique identifier for health care professionals available from the Federal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric identifier. If you have a NPI number, provide this on your application. Legal Name: List your full name: first, middle, and last. Definition of legal name: “Legal name” is the name appearing on your official certificate of birth or, if your name has changed since birth, on an official marriage certificate or an order by a court. The court must have the 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 of your birth. Birth date: Provide the city, state and country where you were born. Address: List the address we should use to send any information about your license. 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 notified 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. Email is the Department’s primary form of communication. Please ensure you are checking your spam folders for correspondence. 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. DOH 644-006 June 2016 Page 1 of 2 FF 2. Other License, Certification, or Registration. List in date order, most recent to later, all credentials you have held since last being credentialed in Washington State. Include your last active credential in Washington State. Attach additional pages if you need more space. FF 3. Experience. List in date order, most recent to later, all your professional work experience since your Washington State credential expired. Attach additional pages if you need more space. FF 4. AIDS Education and Training Attestation. Required by WAC 246-12-040. If AIDS education was included in your professional education or training, an additional course is not required. FF 5. Continuing Education Attestation. Required by WAC 246-12-040. FF 6. Disciplinary Action Attestation. Required by WAC 246-12-040. FF 7. Applicant’s Attestation. Required to be both signed and dated in order to process the application. DOH 644-006 June 2016 Page 2 of 2 Date Stamp Here Revenue 0299050000 Athletic Trainer Expired License Activation Application Please print clearly in ink. Follow all instructions provided. 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. 1. Demographic Information Social Security Number (SSN) (If you do not have a SSN, see instructions) Name First National Provider Identifier Number (NPI) (Enter 10 digit number) Middle Male Female Last Place of birth Birth date (mm/dd/yyyy) City State Country Address City State Zip Code County Country Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #) Email address: Mailing address if different from above address of record City State Zip Code County Country Note: The mailing and email addresses you provide will be your addresses of record. It is your responsibility to maintain current contact information on file with the department. Have you ever been known under any other name(s)? Yes No If yes, list name(s): Will documents be received in another name? Yes If yes, list name(s): No DOH 644-007 June 2016 Page 1 of 3 2. Other License, Certification, or Registration Credential State/Jurisdiction Profession Type Number Year Issued Method of Licensure Currently in force No Yes 3. Professional Experience Type of experience of practice and location Start (mm/yyyy) End (mm/yyyy) 4. AIDS Education and Training Attestation I certify I have completed the minimum of seven hours of education in the prevention, transmission and treatment of AIDS. This includes the topics of etiology and epidemiology, testing and counseling, infection control guidelines, clinical manifestations and treatment, legal and ethical issues to include confidentiality, and psychosocial issues to include special population considerations. I understand I must maintain records documenting said education for two years and be prepared to submit those records to the department if requested. I understand that should I provide any false information, my license may be denied, or if issued, suspended or revoked. If AIDS education was included in your professional education or training, an additional course is not required. Applicant’s Initials Date 5. Continuing Education Attestation I certify I have met all continuing education and competency requirements for the past two years. I am enclosing documentation on all classes attended/claimed. Applicant’s Initials Date DOH 644-007 June 2016 Page 2 of 3 6. Disciplinary Action Attestation I certify no action has been taken by any state or federal jurisdiction or hospital, which would prevent or restrict my right to practice my profession. I further certify I have not voluntarily given up any credential or privilege or have not been restricted in the practice of my profession in lieu of or to avoid formal action. Applicant’s Initials Date 7. Applicant’s Attestation I, _________________________________________ , declare under penalty of perjury under the laws of (Print applicant name clearly) the state of Washington that the following is true and correct: • I am the person described and identified in this application. • I have read RCW 18.130.170 and RCW 18.130.180 of the Uniform Disciplinary Act. • I have answered all questions truthfully and completely. • The documentation provided in support of my application is accurate to the best of my knowledge. • I have read all laws and rules related to my profession. I understand the Department of Health may require more information before deciding on my application. The department may independently check conviction records with state or federal databases. I authorize the release of any files or records the department requires to process this application. This includes information from all hospitals, educational or other organizations, my references, and past and present employers and business and professional associates. It also includes information from federal, state, local, or foreign government agencies. I understand I must inform the department of any past, current or future criminal charges or convictions. I will also inform the department of any physical or mental conditions that jeopardize my ability to provide quality health care. If requested, I will authorize my health providers to release to the department information on my health, including mental health and any substance abuse treatment. Dated____________________________________ at________________________________________ (mm/dd/yyyy) (City, state) By:________________________________________ (Signature of applicant) DOH 644-007 June 2016 Page 3 of 3 (This page intentionally left blank.) Athletic Trainer Credentialing PO Box 47877 Olympia, WA 98504-7877 360-236-4700 Out-of-State Credential Verification To Applicant: Please complete this side of form and send it to the state(s) and/or jurisdiction(s) where you are or have been licensed, certified, or registered as a healthcare provider. Name: Last First Middle Mailing Address City State Zip Code Phone (enter 10 digit #) Cell (enter 10 digit #) Email address Any other names used: Washington State healthcare credential type you are applying for: Washington State healthcare credential number (if available): Date Issued Have the licensing agency return this completed form to the address listed above. If you have any questions, please call 360-236-4700. This form may be duplicated. DOH 644-008 June 2016 Page 1 of 2 (To be Completed by the Regulatory Agency) Please complete this form regarding the applicant listed on the reverse. Submit the completed form and any other requested material directly to this office at the address on the reverse. We will not accept the form if submitted by the applicant. Thank you. Name of license, certification, or registration holder: Authority providing verification: (state, name & title) Type of healthcare license, certification or registration: Healthcare license, certification or registration number: Applicant was credentialed by: Date: FF Written Examination Score: Name of examination: FF Other Examination Date: Score: Name of examination: Is credential current: c Yes No Expiration Date: Is this individual considered to be in good standing in your state? Yes No If “no,” please attach explanation. Has this credential ever been denied? Suspended? Revoked? Surrendered? Reinstated? Yes Yes Yes Yes Yes No No No No No If “yes,” please provide a copy of the final order or other documentation of action taken. If this credential holder has been disciplined, has he/she successfully completed all requirements and is currently in good standing? Yes No (SEAL) Signature: Title: Date: DOH 644-008 June 2016 Page 2 of 2 RCW/WAC and Online Website Links RCW/WAC Links Uniform Disciplinary Act, RCW 18.130 Administrative Procedure Act, RCW 34.05 Administrative procedures and requirements, WAC 246-12 Athletic Trainer Law, RCW 18.250 Athletic Trainer Rules, WAC 246-916 On-line AIDS Training Resources, Reference Page Athletic Trainer Program, Web Page Board of Certification for Athletic Trainers (BOC), http://www.bocatc.org Commission of Accreditation of Athletic Training Education (CAATE), http://www.caate.net/ Get important information about your credential type by subscribing to email alerts. RCW/WAC and Online Website Links June 2016
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