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Fill Out Your Wa Practitioner Application Form

The Washington Practitioner Application (WPA) is an essential form for health care professionals seeking to establish or maintain their practice in Washington State. This application requires detailed personal, educational, and practice information, ensuring compliance with state regulations. To proceed smoothly, it's important to fill out the form accurately and completely.

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Article Structure

The Washington Practitioner Application form serves as a vital tool for healthcare professionals seeking to establish their credentials and licensing within Washington State. Designed to capture comprehensive practitioner information, it includes several key components such as the practitioner's legal name, contact details, and a thorough outline of their professional history. A section is dedicated to collecting details about previous educational background and training, which encompasses undergraduate and medical education, residencies, fellowships, and additional certifications. To ensure accuracy, applicants must supply current copies of essential documents, including a DEA Certificate and professional liability policy. Completion of the form requires careful attention; all sections must be filled out entirely, and any necessary revisions should be clearly documented. Practitioners must also take care to note any overlap between different practice locations and should submit this information alongside the primary application. Additionally, the form asks for a declaration of any disciplinary actions or professional limitations, thereby promoting transparency and facilitating the credentialing process within health care organizations. By meticulously adhering to the instructions provided, practitioners can navigate the application process successfully and establish their professional standing in Washington's healthcare system.

Wa Practitioner Application Example

• Curriculum Vitae (Not an acceptable substitute for completing the application. Dates need to be listed in mm/yyyy Format)

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:

xxxxx-xxxx

Home Telephone Number:

Pager Number:

Cell Phone Number:

E-Mail Address:

(

)

(

)

(

)

Email address

Birth Date: (mm/dd/yyyy)

Birth Place (city, state,

country):

Citizenship:

Social Security Number:

Male

Female

Languages Fluently

Spoken by Practitioner:

Have you ever voluntarily opted-out of Medicare? Yes

NPI:

Medicare Number: (WA)

Medicaid (DSHS) Number(s):

L & I Number(s):

Specialty primarily practicing:

Sub specialties primarily practicing:

Other Professional Interests in Practice, Research, etc.:

Washington Practitioner Application – January 2019

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PRACTICE INFORMATION

CHECK ALL THAT APPLY

Effective Date at PRIMARY Practice location (MM/YY) __________

Practice Setting

Clinic/Group

Solo Practice

Home Based

Hospital Based

Primary Care Site

Urgent Care

Other

Practitioner Profile

PCP

Specialist

Check if you are both PCP & OB OB in your practice

Yes

Deliveries

Yes

Name of Practice / Affiliation or Clinic Name:

Department Name (if hospital based):

Primary Office Street Address:

City:

State:

Zip Code:

Org. NPI#:

Patient Appointment Telephone Number:

Fax Number:

(

)

(

)

Mailing Address: (if different from above)

Billing Address: (if different from above)

Practice Website

Office Manager / Administrator Name:

Administration Telephone Number:

(

)

E-mail Address:

Fax Number:

(

)

Credentialing Contact (if different from above):

Telephone Number:

(

)

E-mail Address:

Fax Number:

(

)

Name Affiliated with Tax ID Number:

Federal Tax ID Number:

Is the office wheelchair accessible?

Yes

Office Hours

Monday: ________________________

Are you accepting new patients?

Yes

Have you limited your practice in any way (e.g. 18 years or older?)

Tuesday: ________________________

Yes

No If yes, please explain:

Wednesday: ______________________

_________________________________________________________

Thursday: ________________________

_________________________________________________________

Friday: __________________________

Do you currently supervise ARNP’s or PA’s?

Yes

Saturday: ________________________

If yes, please provide the name and specialty below:

Sunday:__________________________

_________________________________________________________

Do you provide 24 hour coverage?

Yes

_________________________________________________________

If no, please explain how your patients obtain

Please list languages fluently spoken by office staff:

advice and care after hours:

_________________________________________________________

_________________________________________

_________________________________________________________

_________________________________________

A. Hospital Inpatient Coverage Plan (for those without admitting privileges)		Does Not Apply
Name of Admitting Physician/Practice/Clinic/Group:	Hospital Where privileged:

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

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Effective Date at SECONDARY Practice location (MM/YYYY)

CHECK ALL THAT APPLY

Practice Setting

Clinic/Group

Solo Practice

Home Based

Hospital Based

Primary Care Site

Urgent Care

Other

Practitioner Profile

PCP

Specialist

Check if you are both PCP & OB OB in your practice

Yes

Deliveries

Yes

Name of Secondary Practice / Affiliation or Clinic Name:

Department Name (if hospital based):

Primary Office Street Address:

City:

State:

Zip Code:

Org. NPI#

Patient Appointment Telephone Number:

Fax Number:

(

)

(

)

Mailing Address: (if different from above)

Billing Address: (if different from above)

Practice Website

Office Manager / Administrator Name:

Administration Telephone Number:

(

)

E-mail Address:

Fax Number:

(

)

Credentialing Contact (if different from above):

Telephone Number:

(

)

E-mail Address:

Fax Number:

(

)

Name Affiliated with Tax ID Number:

Federal Tax ID Number:

Is the office wheelchair accessible?

Yes

Office Hours

Monday: ________________________

Are you accepting new patients?

Yes

Have you limited your practice in any way (e.g. 18 years or older?)

Tuesday: ________________________

Yes

No If yes, please explain:

Wednesday: ______________________

_________________________________________________________

Thursday: ________________________

_________________________________________________________

Friday: __________________________

Do you currently supervise ARNP’s or PA’s?

Yes

Saturday: ________________________

If yes, please provide the name and specialty below:

Sunday:__________________________

_________________________________________________________

Do you provide 24 hour coverage?

Yes

_________________________________________________________

If no, please explain how your patients obtain

Please list languages fluently spoken by office staff:

advice and care after hours:

_________________________________________________________

_________________________________________

_________________________________________________________

_________________________________________

A.Hospital Inpatient Coverage Plan (for those without admitting privileges)

Does Not Apply

Name of Admitting Physician/Practice/Clinic/Group:

Hospital Where privileged:

B. Office Covering Practitioners/Call Group				Does Not Apply
B. Office Covering Practitioners/Call Group				Does Not Apply
Provider Name, Degree	Specialty	Address	Phone Number

Attach a list of additional covering practitioners if needed

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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:

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:

ECFMG Number (applicable to foreign medical graduates):	Date Issued:

5.ALL OTHER PROFESSIONAL LICENSES, REGISTRATIONS AND CERTIFICATIONS

State:	Lic/Reg/Cert Number:	Date Issued	Exp. Date	Yr. Relinquish	Reason:

State:	Lic/Reg/Cert Number:	Date Issued	Exp. Date	Yr. Relinquish	Reason:

State:	Lic/Reg/Cert Number:	Date Issued	Exp. Date	Yr. Relinquish	Reason:

6. UNDERGRADUATE EDUCATION (Do not abbreviate)			Does Not Apply
School/College/University/Vocational Education:	Degree Received(be specific, e.g. BS			Graduation Date
	Biology)			(mm/yyyy)

Mailing Address:	City:	State:		Zip Code:

College or University Name:	Degree Received(be	specific, e.g. BS		Graduation Date
	Biology)			(mm/yyyy)

Mailing Address:	City:	State:		Zip Code:

7. MASTER DEGREE PROGRAM OR POST GRADUATE EDUCATION							Does Not Apply
Institution:					Address	City	State	Zip Code:

Dates Attended (mm/yyyy - mm/yyyy):					Program or Course of Study:
(		) - (		)
(	/	) - (	/	)

Faculty Director:					Degree:

8.MEDICAL/PROFESSIONAL EDUCATION (Do not abbreviate)

Medical/Professional School:		Start Date:	Graduation Date	Degree Received
		(mm/yyyy)	(mm/yyyy)

Mailing Address:		City:	State:	Zip Code:

Medical/Professional School:		Start Date	Graduation Date	Degree Received
		(mm/yyyy)	(mm/yyyy)

Mailing Address:		City:	State:	Zip Code:

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9. INTERNSHIP/PGYI (Attach Additional Sheet if Necessary)			Does Not Apply
Institution:	Phone Number:	Fax Number:	Program Director:

Mailing Address:	City:	State:	Zip Code:

Type of Internship:	Specialty:	From (mm/yyyy):	To (mm/yyyy):

10.	RESIDENCIES		(Attach Additional Sheet if Necessary)				Does Not Apply
Institution:					Phone Number:	Fax Number:		Program Director:

Mailing Address:					City:	State:		Zip Code:

Type of Residency:					Specialty:	From (mm/yyyy):		To (mm/yyyy):

Did you successfully complete the program?					Yes	No (If "No", please explain on separate sheet.)
Institution:					Phone Number:	Fax Number:		Program Director:

Mailing Address:					City:	State:		Zip Code:

Type of Residency:					Specialty:	From (mm/yyyy):		To (mm/yyyy):

Did you successfully complete the program?					Yes	No (If "No", please explain on separate sheet.)
11.	FELLOWSHIPS			(Attach Additional Sheet if Necessary)			Does Not Apply
Institution:					Phone Number:	Fax Number:		Program Director:

Mailing Address:					City:	State:		Zip Code:

Course of Study:						From (mm/yyyy):		To (mm/yyyy):

Did you successfully complete the program?					Yes	No (If "No", please explain on separate sheet.)
Institution:					Phone Number:	Fax Number:		Program Director:

Mailing Address:					City:	State:		Zip Code:

Course of Study:						From (mm/yyyy):		To (mm/yyyy):

Did you successfully complete the program?					Yes	No (If "No", please explain on separate sheet.)
12.	PRECEPTORSHIP			(Attach Additional Sheet if Necessary)			Does Not Apply
Institution:					Address:	City:			State:	Zip Code:

Telephone Number					Fax Number		Email		Address
(	)				( )

Dates Attended (mm/yyyy - mm/yyyy):					Training:		Department Chairman:
(	/	) - (	/	)

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13. FACULTY/TEACHING APPOINTMENTS (Attach Additional Sheet if Necessary)

Does Not Apply

Institution:

Address:

City:

State:

Zip Code:

Telephone Number

Fax Number

Address

(

)

( )

Dates Attended (mm/yyyy - mm/yyyy):

Position:

Faculty Director:

(

) - (

)

14.

BOARD CERTIFICATION

Does Not Apply

Are you board or otherwise professionally certified?

Yes If "Yes", please complete

No If "No", describe your intent for certification, if any, and dates of testing for

below:

Certification on separate sheet.

Date Recertified

Expiration Date

Issuing Board/Entity and State Issued

Specialty

Date Certified

(if any)

Have you applied for certification other than those indicated above?

Yes

If so, list certification and date:

Certification number if applicable:

If you participate in a specialty which does not have board certification, please indicate specialty:

15. OTHER CERTIFICATIONS ACLS, BLS, ATLS, PALS, NALS (e.g., Fluoroscopy, Radiography, etc.)

(Attach Certificate if Applicable)

Type:

Number:

Expiration Date:

Type:

Number:

Expiration Date:

16.

HOSPITAL, MILITARY, & OTHER INSTITUTIONAL AFFILIATIONS

Does Not Apply

Please list in reverse chronological order (with the current affiliation(s) first) all institutions where you (A) Current Hospital

affiliation, (B) Previous Hospital Affiliations, (C) Current Military Affiliation, (D) Previous Military Affiliations (E) Applications in

process This includes hospitals, surgery centers, institutions, corporations, military assignments, or government agencies. If

more space is needed, attach additional sheet(s). List only affiliations here, list employment in section XVII, Work History.

A. CURRENT HOSPITAL AFFILIATIONS (Do not abbreviate)

Name of Primary Admitting Hospital:

Department:

Mailing Address

City, State , Zip

Phone number:

Fax Number:

Status (active, provisional, courtesy, temporary, etc.):

Appointment Date (mm/yyyy):

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

Name of Secondary Admitting Hospital:

Department:

Mailing Address

City, State, Zip

Phone number:

Fax Number:

Status:

Appointment Date (mm/yyyy):

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

Washington Practitioner Application – January 2019

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Name of Other Institutions:		Department:

Mailing Address		City, State, Zip

Phone number:		Fax Number:

Status:		Appointment Date (mm/yyyy):

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)

Name of Admitting Hospital:		Department:

Mailing Address		City, State, Zip

Previous Status (active, provisional, courtesy, temporary, etc.):		From (mm/yyyy):		To (mm/yyyy):

Reason for Leaving:

Name of Admitting Hospital:		Department:

Mailing Address		City, State, Zip

Previous Status (active, provisional, courtesy, temporary, etc.):		From (mm/yyyy):		To (mm/yyyy):

Reason for Leaving:

Name of Admitting Hospital:		Department:

Mailing Address		City, State, Zip

Previous Status (active, provisional, courtesy, temporary, etc.):		From (mm/yyyy):		To (mm/yyyy):

Reason for Leaving:

C.CURRENT MILITARY AFFILIATIONS (Do not abbreviate) Please include Military Reserves

Name of Primary Base:	Division

Mailing Address	City, State , Zip

Phone number:	Fax Number:

Status (active, provisional, courtesy, temporary, etc.):	Appointment Date (mm/yyyy):

D. PREVIOUS MILITARY AFFILIATIONS (Do not abbreviate)

Name of Primary Base:			Division

Mailing Address			City, State , Zip

Phone number:			Fax Number:

Status (active, provisional, courtesy, temporary, etc.):			Appointment Date (mm/yyyy):

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E. APPLICATIONS IN PROCESS (Do not abbreviate)

Hospital/Institution:	Phone Number/Fax Number:	Date Application Submitted:

Mailing Address:	City:	State:	Zip Code:

Hospital/Institution:	Phone Number/Fax Number:	Date Application	Submitted(mm/yyyy)

Mailing Address:	City:	State:	Zip Code:

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:			Telephone Number:
				(	)

Reason for Leaving:	Email Address			Fax Number:
				(	)

Mailing Address	City:	State:	Zip:	From (mm/yyyy)		To (mm/yyyy)

Name of Practice / Employer:	Contact Name:			Telephone Number:
				(	)

Reason for Leaving:	Email Address			Fax Number:
				(	)

Mailing Address:	City:	State:	Zip Code:	From (mm/yyyy):		To (mm/yyyy):

Name of Practice / Employer:	Contact Name:			Telephone Number:
				(	)

Reason for Leaving:	Email Address			Fax Number:
				(	)

Mailing Address:	City:	State:	Zip Code:	From (mm/yyyy):		To (mm/yyyy):

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.

	Name of Reference:		Title and Specialty:			E-mail Address:

	Mailing Address:		City:			State:		Zip Code:

	Telephone Number:		Fax Number:			Cell Phone Number: (Optional)
	(	)	(	)		(	)

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Name of Reference:		Title and Specialty:		E-mail Address:

Mailing Address:		City:		State:		Zip Code:

Telephone Number:		Fax Number:		Cell Phone Number:		(Optional)
(	)	(	)	(	)
Name of Reference:		Title and Specialty:		E-mail Address:

Mailing Address:		City:		State:		Zip Code:

Telephone Number:		Fax Number:		Cell Phone Number: (Optional)
(	)	(	)	(	)

20.PROFESSIONAL AFFILIATIONS (Do not abbreviate)

Please List Membership In All Professional Societies
Complete Name of Society:						Date Joined			Current Member
					/		/	.	YES	NO
					/		/	.	YES	NO
21. PROFESSIONAL LIABILITY (Do not abbreviate)
A. Current Insurance Carrier:						Policy Number:

Mailing Address:		City:				State:			Zip Code:

Phone Number:						Fax Number:

Per claim amount:	$	Aggregate amount:	$			Date Began (mm/yyyy):			Expiration Date
									(mm/yyyy):

B. PREVIOUS PROFESSIONAL LIABILITY		CARRIERS WITHIN THE LAST TEN YEARS (Do not abbreviate)
(Attach Additional Sheet if Necessary)
Name of Carrier:						Policy Number:

Mailing Address:		City:				State:			Zip Code:

Phone Number:						Fax Number:

Per claim amount:	$	Aggregate amount:	$			Date Began (mm/yyyy):			Expiration Date
									(mm/yyyy):
Name of Carrier:						Policy Number:

Mailing Address:		City:				State:			Zip Code:

Phone Number:						Fax Number:

Per claim amount:	$	Aggregate amount:	$			Date Began (mm/yyyy):			Expiration Date
									(mm/yyyy):
Name of Carrier:						Policy Number:

Mailing Address:		City:				State:			Zip Code:

Phone Number:						Fax Number:

Per claim amount:	$	Aggregate amount:	$			Date Began (mm/yyyy):			Expiration Date
									(mm/yyyy):
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Name of Carrier:				Policy Number:

Mailing Address:		City:		State:	Zip Code:

Phone Number:				Fax Number:

Per claim amount:	$	Aggregate amount:	$	Date Began (mm/yyyy):	Expiration Date
					(mm/yyyy):
Name of Carrier:				Policy Number:

Mailing Address:		City:		State:	Zip Code:

Phone Number:				Fax Number:

Per claim amount:	$	Aggregate amount:	$	Date Began (mm/yyyy):	Expiration Date
					(mm/yyyy):
Name of Carrier:				Policy Number:

Mailing Address:		City:		State:	Zip Code:

Phone Number:				Fax Number:

Per claim amount:	$	Aggregate amount:	$	Date Began (mm/yyyy):	Expiration Date
					(mm/yyyy):
Name of Carrier:				Policy Number:

Mailing Address:		City:		State:	Zip Code:

Phone Number:				Fax Number:

Per claim amount:	$	Aggregate amount:	$	Date Began (mm/yyyy):	Expiration Date
					(mm/yyyy):

Washington Practitioner Application – January 2019

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Get Wa Practitioner Application PDF Form

Form Characteristics

Fact Name	Details
Document Format	The application must be typed or printed in black or blue ink.
Curriculum Vitae	A CV is not sufficient; completing the application form is mandatory.
Signature Requirement	Applicants must sign and date pages 11 and 13 of the application.
Completeness	All sections of the form must be completed in full, without any abbreviations.
Document Attachments	Copies of required documents such as the DEA Certificate must accompany the application.
Changes to Application	If edits are needed, applicants should strike out incorrect information, write in the changes, and then initial and date those changes.
Health Care Organization Identification	Applicants must specify the healthcare organization(s) for which they are submitting this application.
Obtaining Addendums	Expect to receive addendums from requesting organizations for any omitted information.

Guidelines on Utilizing Wa Practitioner Application

Completing the Washington Practitioner Application form requires careful attention to detail to ensure all necessary information is accurately provided. After this application has been filled out and reviewed for completeness, you will need to submit it along with required supporting documents.

Start by typing or printing the application legibly in black or blue ink. Make sure not to abbreviate any terms.
Prepare your Curriculum Vitae in the required format. Dates should be listed in mm/yyyy format.
Keep an unsigned and undated copy of the application for your records.
Fill in your legal name in the Practitioner Information section, including any suffixes. Include your home address, telephone numbers, and email information.
Provide your birth date, birth place, citizenship, and social security number in the designated areas.
Indicate your primary language and if you opted out of Medicare at any point.
Complete the Practice Information section, noting the effective date, practice setting, and your practice profile.
Document the name of your practice or affiliation, along with its contact information and organization NPI number.
Fill out details regarding office accessibility, office hours, and whether you are accepting new patients.
Provide licensing and registration information, including dates and numbers for the Washington State Professional License.
List your educational background, including undergraduate, graduate, and medical education without abbreviations.
Include your internship, residency, and fellowship information, providing institution names, specialties, and completion status.
Attach copies of all requested documents such as your DEA certificate and liability insurance face sheet.
Check each section for completeness and accuracy before signing and dating pages 11 and 13. Address any "yes" responses on the Attestation Question page.
If you notice any needed changes after completion, revise the information by striking out the error, making the correction, and then initialing and dating the change.
Submit the application along with all accompanying documents to the appropriate health care organizations.

What You Should Know About This Form

What documents are required to submit with the Washington Practitioner Application?

Applicants must submit a completed application along with the following documents: a current DEA Certificate and a face sheet of the Professional Liability Policy or Certificate. All required documents must accompany the application each time it is submitted to ensure completeness and compliance with the application guidelines.

How should the Washington Practitioner Application form be filled out?

The application should be typed or printed clearly in black or blue ink. Each section must be completed; if additional space is needed, applicants may attach extra sheets and reference the questions being answered. The use of abbreviations is discouraged to maintain clarity throughout the application process.

What should an applicant do if they need to make changes to the submitted application?

If changes are necessary after the application has been completed, applicants should strike out the incorrect information, write in the correct details, and initial and date the changes. This ensures that all modifications are properly documented and verified.

Is it necessary to document any affirmative answers on the application?

Yes, if any "YES" responses are given to the Attestation Questions, these must be documented in the appropriate section of the application. This helps maintain transparency and allows the reviewing organization to assess the applicant's background accurately.

How should an applicant handle sections of the application that do not apply to them?

In instances where a section of the application does not pertain to the applicant, they should simply check the designated box at the top of that section. This indicates to reviewers that the section is not applicable without requiring further explanation.

What should be done if the applicant's name has changed?

If an applicant is known by a name different from their legal name, they must list all previous names in the space provided on the application. This ensures that all licensing and educational institutions can be accurately linked to the applicant's current application.

What is the process for keeping a copy of the Washington Practitioner Application?

It is recommended to retain an unsigned and undated copy of the completed application for future reference. When a request for the application is received, this copy can be referenced to ensure all information is complete, current, and accurate before submission.

What are the contact details required for the office administrator and credentialing contacts?

Applicants must provide the names, telephone numbers, email addresses, and fax numbers of their office administrator and credentialing contact, if applicable. This information helps organizations reach the correct individuals for any follow-up questions or clarifications regarding the application.

Common mistakes

When completing the Washington Practitioner Application (WPA), many individuals inadvertently make mistakes that can delay their submission or cause it to be rejected altogether. Understanding these common errors can help ensure a smoother process for aspiring practitioners.

One frequent oversight occurs in the formatting of dates. The application explicitly requires dates to be documented in a specific format: mm/yyyy. Failure to adhere to this guideline can render the application incomplete. Practitioners should double-check each date entry, from their birth date to the dates of internships and residencies, ensuring they align with the required format.

An additional common error involves neglecting to sign and date the form. Pages 11 and 13 specifically require the applicant's signature and date. Skipping this seemingly minor step can lead to unnecessary delays. Remember, a duly signed application is not merely a formality; it serves as a declaration of the accuracy of the provided information.

Furthermore, applicants sometimes forget to document any affirmative answers on the Attestation Question Page. Responses marked with "Yes" must be substantiated by clearly documenting the details in the space provided. Omitting this information not only detracts from the completeness of the application but could also raise red flags during the review process.

Another common misstep is failing to identify the specific health care organization or organizations to which the application is being submitted. This information is crucial for the review process. Leaving this section blank can lead to confusion or misdirection in the evaluation of the application, ultimately prolonging the timeline.

In addition, many practitioners might overlook the necessity of attaching all required documentation. Key documents like the DEA certificate and face sheet of the professional liability policy must accompany the application. Missing these documents could result in the application being deemed deficient, thus necessitating a resubmission.

Some applicants also forget to check the provided boxes for sections that do not apply to their situation. This step is essential; without it, reviewers may assume that pertinent information has been omitted rather than classified as inapplicable, causing further complication in the review process.

Lastly, when modifications to the application are necessary, there is a proper way to document these changes. Striking out incorrect information and writing in the corrections, along with initialing and dating these adjustments, is the recommended approach. Failing to follow this protocol can undermine the credibility of the application.

By paying attention to these common pitfalls, aspiring practitioners can enhance their chances of successfully navigating the application process. Thoroughness and attention to detail are essential components of this endeavor, leading to a more efficient and successful submission.

Documents used along the form

The Washington Practitioner Application form requires several supporting documents to ensure a complete submission. Each document plays a vital role in the evaluation process for healthcare practitioners. The following is a list of commonly required forms and documents that should accompany the application.

Curriculum Vitae (CV): A detailed summary of the practitioner's education, work experience, and qualifications. It provides context for the applicant’s skills and background. Ensure that dates are formatted as mm/yyyy.
DEA Certificate: This certificate verifies the practitioner's registration with the Drug Enforcement Administration to prescribe controlled substances. A current copy is essential for the application.
Professional Liability Insurance Certificate: A document that confirms coverage in case of malpractice claims. Submitting it helps demonstrate that the practitioner has professional liability insurance.
Attestation Question Page: This page allows the applicant to affirm the accuracy of their application and document any affirmative responses to the attestation questions, which may require additional clarification.
Covering Practitioners Information: If the applicant supervises other practitioners, this document lists those individuals, including their specialties and contact information, ensuring that adequate care coverage is maintained.

Including these documents will facilitate a smoother application process. Each supports the information presented in the Washington Practitioner Application and helps to meet the credentialing requirements of the healthcare organization involved.

Similar forms

Credentialing Application - Both the Wa Practitioner Application and a credentialing application require comprehensive details regarding the applicant's qualifications, work history, and any applicable certifications.
Medical License Application - Similar to the Wa Practitioner Application, the medical license application mandates thorough documentation of educational background, practice information, and any disciplinary history.
DDEA Registration Application - This application also necessitates providing identification details, practice settings, and proof of qualifications, mirroring the requirements of the Wa Practitioner Application.
Insurance Application - Like the Wa Practitioner Application, an insurance application requires specific personal and practice-related information essential for risk assessment by the insurer.
Medicare Enrollment Application - The process of applying for Medicare enrollment is similar in that it requires personal identification, evidence of qualifications, and practice location details.
Subspecialty Certification Application - Both applications necessitate submission of information that showcases ongoing medical education and specialty training.
Continuing Education Credit Application - This application format is alike in its need for listing educational experiences, dates, and related professional activities.
State Medical Board Application - As with the Wa Practitioner Application, the state medical board application calls for extensive background checks, including previous licenses and professional conduct inquiries.

Dos and Don'ts

Do keep a signed and dated copy of the application for your records.
Do complete all sections of the application fully.
Do document any “YES” responses on the Attestation Question page.
Do use black or blue ink, and type the application if possible.
Do attach all requested documents each time you submit the application.
Don't submit your Curriculum Vitae in place of the application.
Don't abbreviate any terms or information when filling out the application.

Misconceptions

Misconceptions about the Washington Practitioner Application form can lead to confusion and errors in the application process. Here are seven common misunderstandings:

Curriculum Vitae Sufficiency: Some believe that a CV is enough to fulfill application requirements. In reality, applicants must complete the application form fully, as a CV cannot substitute for the specific information requested.
Unsigned Application: Many assume that submitting an unsigned application is acceptable. However, signing and dating pages 11 and 13 is mandatory for the application to be considered valid.
Omission of YES Responses: A misconception persists that applicants can skip documenting any YES responses on the Attestation Question page. This information is crucial for the review process and must be provided accurately.
Document Submission Flexibility: Some applicants think they can submit the application without attaching all required documents. Each time the application is submitted, copies of the requested documents must be included to ensure completeness.
Section Exemptions Without Notation: Individuals often believe that if a section does not apply to them, they can just leave it blank. In fact, it is essential to check the provided box indicating non-applicability to prevent delays.
Verbal Modifications: There is a common belief that verbal changes to the application will be accepted. Instead, if modifications are necessary, applicants must strike out the information, write in the changes, and initial and date them to maintain clarity.
No Need for Copies of Applications: Some individuals think that it is unnecessary to keep an unsigned copy of the application on file. However, maintaining a copy is recommended for future reference and potential requests.

Understanding these misconceptions can streamline the application process and reduce unnecessary complications. Clarity and accuracy are vital for a successful application.

Key takeaways

Filling out and using the Washington Practitioner Application (WPA) form requires attention to detail and adherence to specific instructions. The following key takeaways will guide you through the process.

Complete All Sections: It is crucial to fill out every section of the application. Missing information may delay processing. Specific formats, such as mm/yyyy for dates, must be followed.
Sign and Document: Remember to sign and date pages 11 and 13 of the application. Any affirmative answers on the Attestation Question page need to be documented for clarity.
Attach Required Documents: Each submission must include copies of essential documents, such as the DEA Certificate and professional liability policy face sheet. These documents support your application and verify your credentials.
Keep Records: Maintain an unsigned and undated copy of your application for future reference. This helps in resubmissions or updates when needed and ensures you have a record of the information provided.

These takeaways can help streamline the application process, ensuring accurate and timely submissions.

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