Applicant’s Attestation. You must sign and date this for us to process the application. Examination: Professional assistance for test takers with disabilities must submit the request for ADA accommodations to the program 30 days prior to the scheduled exam date. The request must include a written verification from a health care provider. The answer to many frequently asked questions may be found online. We appreciate your interest in obtaining a credential. You will be notified in writing if further documentation is required. If your application is incomplete, you will be mailed or emailed a letter regarding the deficiencies. • The application is considered incomplete if requested information is left blank. Put N/A or place a line through a section instead of leaving it blank. • The initial credential will expire on your birthday unless the credential is issued within 90 days of your next birthday. See WAC 246-12-020(3). • You must keep your address up to date in order to receive a courtesy renewal notice. Any renewal postmarked or presented to the department after midnight on the expiration date is late. For Spouses and Registered Domestic Partners of Military Personnel Being Transferred or Stationed in Washington: Under state law, if you are the spouse or state-registered domestic partner of a servicemember of any branch of the U.S. Military, to include Guard or Reserve, and are applying for a health care professional credential in this state, you may be eligible to have the processing of your application expedited to receive your credential more quickly. Documents to submit with your application should include the following: • A copy of your spouse’s or registered domestic partner’s military transfer orders to Washington State. • One of the following: - A copy of your marriage certificate to show proof of marriage; or - A copy of a state’s declaration or registration showing you are in a state registered domestic partnership with a member of the U.S. military. (This page intentionally left blank.) Date Stamp Here Revenue: 0207080000 Certified Advisor Credential Application Please print clearly. It is the responsibility of the applicant to submit or request all required supporting documents be submitted. Failure to do so may result in a delay in processing your application. Select if the following applies: ⬜ Spouse or Registered Domestic Partner of Military Personnel
Applicant’s Attestation. You must sign and date this for us to process the application. Delegation Agreement Application • Complete the Osteopathic Physician Assistant application form and submit the documents required for an original license or have a current osteopathic physician assistant license. • Completed delegation agreement. • If you transfer from a Washington physician supervisor (either MD or DO), you must have verification letters sent directly from all hospitals where you were granted privileges during the past working relationship. • Letter of evaluation from previous supervising physician. Prescriptive Authority A certified osteopathic physician assistant or interim permit holder can issue written or oral prescriptions as provided in WAC 000-000-000 when approved by the board and assigned by the supervising physician.
