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Medical Assistant-Phlebotomist CertificationApplication PacketContents:1. 651-007. Contents List/SSN Information/Mailing Information. 1 page2. 651-008. Application Instructions Checklist. 3 pages3. 651-009. Credentialing Requirements. 1 page4. 651-010. Medical Assistant-Phlebotomist Certification Application. 5 pages5. RCW/WAC and Online Website Links. 1 pageImportant Social Security Number Information:You are required by state and federal law to provide a social security number with yourapplication. If you do not have a social security number at the time you send in thisapplication, please read, complete, and return this form with your application.A U.S. Individual Taxpayer Identification Number (ITIN) or a Canadian Social InsuranceNumber (SIN) cannot be substituted.In order to process your request:Mail your application with initialdocumentation and your checkor money order payable to:Send other documents not sent withinitial application to:Department of HealthP.O. Box 1099Olympia, WA 98507-1099Medical Assistant CredentialingP.O. Box 47877Olympia, WA 98504-7877Contact us:360-236-4700To request this document in another format, call 1-800-525-0127. Deaf or hard ofhearing customers, please call 711 (Washington Relay) or email civil.rights@doh.wa.gov.DOH 651-007 June 2020

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Application Instruction ChecklistImportant background check information: Washington State law authorizes theDepartment of Health to obtain fingerprint-based background checks for licensingpurposes. This check may be through the Washington State Patrol and the FederalBureau of Investigation (FBI). This may be required if you have lived in another state orif you have a criminal record in Washington State. This would be at your own expense.All information should be printed clearly in blue or black ink. It is your responsibility tosubmit the required forms.FF Application Fee: (This fee is non-refundable). You can check the onlinefee page for current fees.FF Check if either apply:Request for Military Training and Experience EvaluationSpouse or Registered Domestic Partner of Military PersonnelFF 1. Demographic Information:Social Security Number: You must list your social security number on yourapplication. Please call the Customer Service Center at 360-236-4700 if you do nothave one.National Provider Identifier Number (NPI): The National Provider Identifier (NPI)is a standard unique identifier for health care professionals available from theFederal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numericidentifier. If you have a NPI number, provide this on your application.Legal Name: List your full name: first, middle, and last.Definition of Legal Name: “Legal name” is the name appearing on your officialcertificate of birth or, if your name has changed since birth, on an official marriagecertificate or an order by a court. The court must have legal authority to changeyour name. We may ask you to prove your legal name. If you use any name otherthan your legal name on this form, your application may be denied.Birth date: Provide the month, day, and year you were born.Address: List the address we should use to send any information about yourcertification. Be sure to include the city, state, zip code, county, and country. Thiswill be your permanent address with Department of Health until we have beennotified of a change, See WAC 246-12-310.Phone, Fax and Cell Numbers: Enter your phone, fax and cell numbers, if youhave them.Email: Enter your email address, if you have one.Other Name(s): Indicate whether you are known or have been known under anyother names. If you have a name change, you must notify the Department of Healthin writing. You must include proof of this change. See WAC 246-12-300.DOH 651-008 June 2020Page 1 of 3

2. Personal Data Questions:All applicants must answer the same personal data questions. They are focused onyour fitness to practice the essential skills of this profession.If you answer “yes” to any questions in this section, you must provide anappropriate explanation. You must provide the documentation listed in the noteafter the questions. If you do not provide this, your application is incomplete and itwill not be considered. Question 5 includes misdemeanors, gross misdemeanors and felonies. Youdo not have to answer yes if you have been cited for traffic infractions. Youcan obtain copies of court records through the county courthouse where theconviction, plea, deferred sentence, or suspended sentence was entered. If you have been granted certificate(s) of restoration of opportunity, pleaseprovide a certified copy of each certificate. Another jurisdiction means any other country, state, federal territory, or militaryauthority.FF 3. Training and Education:List in date order your training and education and practice. Attach additional pagesif you need more space.FF 4. Experience:List in date order your professional work experience. Attach additional pages if youneed more space.FF 5. Other License, Certification, or Registration:List all states, including Washington, where credentials are or were held. Attachadditional completed pages if you need more space. You must also print theVerification Form and provide it to each state or jurisdiction that you have listed,requesting that they complete and submit the form directly to the Department ofHealth.FF 6. Qualifications and Training Attestation:You must meet the Qualification and Training Requirements. You must sign anddate this as proof of completion.FF 7. Phlebotomy Training and EducationSelect the training and education you have completed.FF 8. Applicant Attestation and Signature:You must sign and date this for us to process the application.DOH 651-008 June 2020Page 2 of 3

For Spouses and Registered Domestic Partners of MilitaryPersonnel Being Transferred or Stationed in Washington:Under state law, if you are the spouse or state-registered domestic partner of aservicemember of any branch of the U.S. Military, to include Guard or Reserve, andare applying for a health care professional credential in this state, you may be eligibleto have the processing of your application expedited to receive your credential morequickly.Documents to submit with your application should include the following: A copy of your spouse’s or registered domestic partner’s military transfer ordersto 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 stateregistered domestic partnership with a member of the U.S. military.For Current and Former Servicemembers RequestingEvaluation of Military Training and ExperienceUnder state law, your military education, training, and experience may count towardsattaining certain civilian health care profession credentials in Washington State.Submitted information will be reviewed by the Department of Health to determinesubstantial equivalency for meeting the credentialing requirements in this state.Documents to submit with your health care professional credential application shouldinclude the following: If applicable, a copy of your DD214 Certificate of Release or Discharge fromActive Duty, Member-4 or service 2 copy, or NGB-22 for National Guard.Please note:-- A copy of your DD214 can be downloaded from the EBenefits website.-- You can request a replacement copy of your NGB-22 on theNational Archives website. Official Joint Service Transcript (JST) or Community College of the AirForce(CCAF) Transcripts.Please note:-- JST can be sent electronically by visiting the JST website and selectingWashington State Department of Health.-- CCAF transcripts cannot be sent electronically. See the CCAF website fortranscript information.Verification of Military Experience and Training (VMET) or DD Form 2586. Seethe DoDTAP website. If applicable, application for the Evaluation of Learning Experiences DuringMilitary Service (DD Form 295). See the Military Resources website.DOH 651-008 June 2020Page 3 of 3

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Credentialing RequirementsThank you for applying to become a medical assistant-phlebotomist in WashingtonState. In order to qualify for certification you must complete the following.FF Complete and submit the application, with a original signature, date, and fee.FF Sign and date the application as proof of: Completion of high school education or its equivalent. The ability to read, write, and converse in the English language.FF Education and Training:a. Successful completion of a phlebotomy program through a post secondaryschool or college accredited by a regional or national accrediting organizationrecognized by the U.S. Department of Education. Have your accredited postsecondary school or college mail your phlebotomy program official transcriptsdirectly to the Department with the date of completion listed.Or;b. Successful completion of a phlebotomy training program as attested bythe phlebotomy training program’s Washington State licensed supervisinghealthcare practitioner as defined under RCW 18.360.010(3).Or;c. Military training or experience satisfies the training or experience requirementsunless the secretary determines that the military training or experience is notsubstantially equivalent to the standards of this state. Provide official transcriptsshowing proof of your education, training, and experience.FF Experience:List in date order your professional experience and practice from date of completionfrom your accredited phlebotomy program or phlebotomy training program. Includethe month, day, and year. Attach additional pages if you need more space.FF Seven hours of AIDS education and training as required under WAC 246-827.FF Out-of-State Credential Verification form sent to each state where you hold or haveheld a credential. The state will complete its portion of the verification form and mailit directly back to Washington State.Note: You may not practice as a medical assistant-phlebotomist without a validcredential.DOH 651-009 June 2020

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DateStampHereMedical Assistant CredentialingP.O. Box 1099Olympia, WA 98507-1099Revenue: 0252625081Medical Assistant-Phlebotomist Certification ApplicationPlease print clearly. It is the responsibility of the applicant to submit all supporting documentation. Failure to do somay result in a delay in processing your application.Select if either apply:c Request for Military Training and Experience Evaluationc Spouse or Registered Domestic Partner of Military Personnel1. Demographic InformationSocial Security Number (SSN)(If you do not have a SSN, see instructions)NameFirstNational Provider Identifier Number (NPI)(Enter 10 digit number)Middle Male FemaleLastBirth date (mm/dd/yyyy)AddressCityStateZip CodeCountyCountryPhone (enter 10 digit #)Fax (enter 10 digit #)Cell (enter 10 digit #)Email addressMailing address if different from above address of recordCityStateZip CodeCountyCountryNote: The mailing and email addresses you provide will be your addresses of record. It is yourresponsibility to maintain current contact information on file with the department.Have you ever been known under any other name(s)? Yes NoIf yes, list name(s):Will documents be received in another name? Yes NoIf yes, list name(s):DOH 651-010 June 2020Page 1 of 5