Washington Medical Commission
PO Box 47866
Olympia, WA 98504-7866
360-236-2750
Request for Retired Active Physician License
WAC 246-919-480—Retired active license.
1. To obtain a retired active license a physician must comply with chapter 246-12 WAC, Part 5, excluding
WAC 246-12-120 (2)(c) and (d).
2. A physician with a retired active license may not receive compensation for health care services;
3. A physician with a retired active license may practice only in emergent or intermittent circumstances; and
4. Physicians with a retired active license must renew every two years and must report one hundred hours of
continuing medical education at every renewal.
The following requirements must be met to place licensure in retired active status.
You must have a current active Washington State license.
• All fees are non-refundable. You can check the online fee page for current fees. Please select one:
In State and volunteering $100.00 for two years
In State and fully retired/not volunteering $332.00 for two years
Out of State retired active $332.00 for two years
• 100 hours of continuing medical education (CME’s) is required every two years for renewal.
Applicant’s Name: First Middle Last
Date of Birth (mm/dd/yyyy):
License Number:
Email Address:
Address:
City:
State:
Zip Code:
County:
By submitting this form, I understand I am satisfying the requirement of notifying the department, as indicated in
WAC 246-12-120(1). I hereby request that my license be changed to a retired active license. I certify that I have read
the above quoted Washington Administrative Code, and that I will comply with all terms and conditions as stated.
I understand that any misrepresentation in obtaining the retired active license constitutes grounds for disciplinary
action against my license under RCW 18.130.180(2).
I hereby certify that I have met all requirements for continuing medical education (CME’s) and have documentation,
which I will furnish upon request.
Date _____________________
Signature
DOH 657-132 June 2020
