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Respiratory Care Practitioner License ApplicationPacketContents:1. 680-023 Contents List/SSN Information/Mailing Information.1 page2. 680-020 Application Instructions Checklist.3 pages3. 680-021 License Requirements.2 pages4. 680-001 Respiratory Care Practitioner License 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 sentwith initial application to:Department of HealthCredentialingP.O. Box 1099Olympia, WA 98507-1099Respiratory Care PractitionerContact us:P.O. Box 47877Olympia, WA 98504-7877360-236-4700To 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 680-023 June 2020

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Application Instructions ChecklistImportant background check Information: Washington State law authorizes the Departmentof Health to obtain fingerprint-based background checks for licensing purposes. Thischeck may be through the Washington State Patrol and the Federal Bureau ofInvestigation (FBI). This may be required if you have lived in another state or if you havea criminal record in Washington State. This would be at your own expense.All information should be printed clearly in ink. It is your responsibility to submit therequired forms.FF Application Fee. This fee is non-refundable. You can check the fee page forcurrent 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 the 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 your month, day, and year of birth.Address: List the address we should use to send any information on your license.Be sure to include the city, state, zip code, county, and country. This will be yourpermanent address with the Department of Health until we have been notified of achange. 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 246-12-300DOH 680-020 June 2020Page 1 of 3

FF 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 also provide the documentation listed in the noteafter the question. If you do not provide this, your application is incomplete and itwill not be considered.yy Question 5 includes misdemeanors, gross misdemeanors and felonies. You donot have to answer yes if you have been cited for traffic infractions. You can getcopies of court records through the county courthouse where the conviction,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.yy Another jurisdiction means any other country, state, federal territory, or militaryauthority.FF 3. Other License, Certification or Registration:List all states, including Washington, where credentials are or were held. Attach additionalcompleted pages if you need more space. You must also print the Verification Form andprovide it to each state or jurisdiction that you have listed, requesting that they completeand submit the form directly to the Department of Health.FF 4. Examination Data:Official verification of the NBRC entry level examination in the form of scores orcertificate must be sent directly from NBRC to the Department of Health.FF 5. Education:List in date order all high school and college education. Please request officialtranscripts to be sent directly from your college or university to the Department ofHealth. If you need more space, attach a sheet of paper.FF 6. Experience:List in date order all of your experience. If you need more space, attach a sheet ofpaper.FF 7. Applicant’s Attestation:You must sign and date this for us to process the application.DOH 680-020 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 680-020 June 2020Page 3 of 3

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License RequirementsThank you for applying to become a respiratory care practitioner in Washington State. Toexpedite the process, please include the following in your application.FF Education:An applicant must be a graduate of a two-year respiratory therapy educationalprogram. Programs must be Accredited by the Committee On Accreditationfor Respiratory Care or by the American Medical Association’s Committee onAllied Health Education and Accreditation, or its successor, the Commission onAccreditation of Allied Health Education Program.FF Official Transcripts:Your transcripts must indicate the degree and date conferred. The transcripts mustcome directly from your college or university to the Department of Health.FF National Examination Scores:If you have taken and passed the National Board for Respiratory Care (NBRC) entrylevel examination, you meet the minimum examination requirements. The NBRCmust send verification of your passing score directly to us. RCW 18.89.110,WAC 246-928-540.FF If you completed a one-year respiratory therapy education program you may qualifyfor license. You must meet the educational criteria as established by NBRC to sit forthe NBRC’s advanced practitioner exams. If you have been issued the registeredrespiratory therapist credential by the NBRC, you may be considered to have metthe educational criteria. The NBRC must send verification of your passing scoredirectly to us. RCW 18.89.110, WAC 246-928-540.FF Temporary Practice:(New graduates) If you are a recent graduate and your transcripts are not available,you may temporarily practice upon submission of a letter from your program directorverifying successful program completion and date of graduation. A full license will notbe issued until we receive an official transcript. RCW 18.89.090, WAC 246-928-530.yy Temporary practice is available only to graduates who are awaiting the NBRCexam and have graduated from an approved program. RCW 18.89.090,WAC 246-928-530.yy You must sit and pass the examination within ninety days of graduation.RCW 18.89.090, WAC 246-928-530.yy An applicant who receives notification that s/he passed the examinationmay continue to practice under the supervision of a licensed respiratory carepractitioner until the department has issued a license to the applicant.yy An applicant who receives notification of failure to pass the examination mustcease practice immediately. The applicant can begin practicing again only afterpassing the examination and becoming licensed as a respiratory care practitionerby the department.DOH 680-021 June 2020Page 1 of 2