Athletic Trainer Expired License Activation Application 644 007 644005

User Manual: 644-007

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Page Count: 11

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 Verication 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 Identication 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 Send other documents not sent
money order payable to: with initial application to:
Department of Health Athletic Trainer Credentialing
P.O. Box 1099 P.O. Box 47877
Olympia, WA 98507-1099 Olympia, WA 98504-7877
Contact us:
360-236-4700
DOH 644-005 June 2016
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DOH 644-006 June 2016 Page 1 of 2
You will be notied 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:
FPay Late Renewal Penalty Fee.
FPay Current Renewal Fee.
FPay Expired License Reactivation Fee.
All fees are non-refundable. You can check the fee page for current fees.
F1. 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 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 ofcial
certicate of birth or, if your name has changed since birth, on an ofcial marriage
certicate 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 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. 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.
Application Instructions Checklist
F2. Other License, Certication, 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.
F3. 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.
F4. 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.
F5. Continuing Education Attestation. Required by WAC 246-12-040.
F6. Disciplinary Action Attestation. Required by WAC 246-12-040.
F7. 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
DOH 644-007 June 2016 Page 1 of 3
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 different from above address of record
City State Zip Code County
Birth date (mm/dd/yyyy)
City State Country
1. Demographic Information
Place of birth
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.
Revenue 0299050000
Social Security Number (SSN)
(If you do not have a SSN, see instructions) F Male
F Female
National Provider Identier Number (NPI)
(Enter 10 digit number)
DOH 644-007 June 2016 Page 2 of 3
2. Other License, Certication, or Registration
3. Professional Experience
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 condentiality, 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
Type of experience of practice and location Start (mm/yyyy) End (mm/yyyy)
State/Jurisdiction Profession Type Number Year Issued No Yes
Currently in
force
Credential Method of
Licensure
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 3 of 3
7. Applicant’s Attestation
I, ________________________________________ , declare under penalty of perjury under the laws of
the state of Washington that the following is true and correct:
• I am the person described and identied 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 les 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 _______________________________________
By: _______________________________________
(Signature of applicant)
(Print applicant name clearly)
(mm/dd/yyyy) (City, state)
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.
6. Disciplinary Action Attestation
Applicant’s Initials Date
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DOH 644-008 June 2016 Page 1 of 2
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, certied, or registered as a healthcare provider.
Out-of-State Credential Verication
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.
Washington State healthcare credential number (if available): Date Issued
Name: Last First Middle
Mailing Address
Any other names used:
City State Zip Code
Washington State healthcare credential type you are applying for:
Phone (enter 10 digit #) Cell (enter 10 digit #)
Email address
Athletic Trainer Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700
DOH 644-008 June 2016 Page 2 of 2
Please complete this form regarding the applicant listed on the reverse. Submit the completed
form and any other requested material directly to this ofce at the address on the reverse. We
will not accept the form if submitted by the applicant. Thank you.
Name of license, certication, or registration holder:
Authority providing verication: (state, name & title)
Applicant was credentialed by: Date: Score:
FWritten Examination
Name of examination:
FOther Examination Date: Score:
Name of examination:
Is credential current:
F Yes F No Expiration Date:
Is this individual considered to be in good standing in your state? F Yes F No
Has this credential ever been denied? F Yes F No
Suspended? F Yes F No
Revoked? F Yes F No
Surrendered? F Yes F No
Reinstated? F Yes F No
If “yes,” please provide a copy of the nal 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? F Yes F No
Signature:
Title:
Date:
(SEAL)
(To be Completed by the Regulatory Agency)
If “no,” please attach explanation.
Type of healthcare license, certication or registration:
Healthcare license, certication or registration number:
RCW/WAC and Online Website Links June 2016
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 Certication 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.

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