DOH 667-033 September 2021 Page 1 of 2
You will be notied in writing if further documentation is required.
To ensure that you have submitted the necessary fees and documentation, we encourage
you to use the following checklist:
F Pay Late Renewal Penalty Fee.
F Pay Current Renewal Fee.
F Pay Expired Certication Reissuance Fee.
All fees are non-refundable. You can check the fee page for current fees.
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 Identier Number (NPI): The National Provider Identier (NPI) is
a standard unique identier for health care professionals available from the Federal
Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric identier. If
you have a NPI number, provide this on your application.
Legal Name: List your full name: rst, middle, and last
Denition of legal name: “Legal name” is the name appearing on your ocial
certicate of birth or, if your name has changed since birth, on an ocial marriage
certicate 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.
Address: List the address we should use to send any information on your
certication. 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 notied 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 Instructions Checklist