Medical Assistant-Certied Expired Reactivation
Application Packet
Contents:
1. 651-027 .... Contents List/SSN Information/Mailing Information ...................1 page
2. 651-028 .... Application Instructions Checklist ............................................ 2 pages
3. 651-029 .... Medical Assistant-Certied Expired Activation Application ..... 3 pages
4. RCW/WAC and Online Website Links..........................................................1 page
Important Social Security Number Information:
If you have a Social Security Number, the law requires you to disclose it on your
application for a professional or occupational license. 42 U.S.C. § 666(a)(13); RCW
26.23.150. It will be used under the state’s child support enforcement program to locate
individuals for purposes of establishing paternity and establishing, modifying, and
enforcing support obligations. You are not required to have or obtain a Social Security
Number to apply for or obtain a license from the Department of Health. If you do not
have a Social Security Number, you are still eligible to apply for and obtain a credential
if you meet the requirements. Please see the Declaration of No Social Security Number
Form. Please call the Customer Service Center at 360-236-4700 if you have questions.
In order to process your request:
Mail your application with initial
documentation and your check Send other documents not sent
or money order payable to: with initial application to:
Department of Health Medical Assistant Credentialing
P.O. Box 1099 P.O. Box 47877
Olympia, WA 98507-1099 Olympia, WA 98504-7877
Contact us:
360-236-4700
To request this document in another format, call 1-800-525-0127. Deaf or hard of
hearing customers, please call 711 (Washington Relay) or email civil.rights@doh.
wa.gov.
DOH 651-027 September 2023
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DOH 651-028 September 2023 Page 1 of 2
You will be notied in writing if more documentation is needed. We encourage you
to use the following checklist to ensure you have submitted the necessary fees and
documentation.
F Pay Late Penalty Fee.
F Pay Current Renewal Fee.
F Pay Expired Certication Reissuance Fee. All fees are non-refundable. You can
check the online 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 Identier Number (NPI): The National Provider Identier (NPI)
is a standard unique identier for health care professionals available from the
Federal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric
identier. If you have a NPI number, provide this on your application.
Legal Name: List your full name: rst, middle, and last.
Denition of legal name: “Legal name” is the name appearing on your ocial
certicate of birth or, if your name has changed since birth, on an ocial marriage
certicate 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 about your
credential. 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 notied
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.
F 2. Other License, Certication, or Registration: List all credentials you have held
since last being credentialed in Washington State. List in date order, most current
rst. Include your last active credential in Washington State. Attach additional
pages if you need more space. A Credential Verication form may be sent to each
state where you hold or have held a credential. The state will complete its portion
of the form and mail it directly to the Department of Health.
Application Instructions Checklist
F 3. Experience:
List in date order, all your professional work experience and practice since your
Washington State credential expired. Attach additional pages if you need more
space.
F 4. Disciplinary Action Attestation: Required by WAC 246-12-040.
F 5. National Certication or Examination: A person holding an expired medical
assistant credential may not practice until the credential is returned to active status.
1. If your medical assistant credential has been expired for three years or more,
you shall:
(a) Meet the requirements of WAC 246-12-020 through WAC 246-12-051; and
(b) If you currently practice as a medical assistant in another state or U.S.
jurisdiction, please provide verication of your current unrestricted active
medical assistant credential which is substantially equivalent to the
qualications for your credential in the state of Washington.
2. If you have been expired for three years or more and are not currently
practicing, you shall meet the requirements of WAC 246-12-020 through
WAC 246-12-051; and demonstrate competence in one of the following ways:
A medical assistant-certied must successfully pass an examination as identied
in WAC 246-827-0200 within six months prior to reapplying for the credential
or currently hold a national medical assistant certication with a national
examining organization approved by the Secretary. A medical assistant
certication examination approved by the Secretary means an examination that:
• Is oered by a medical assistant program that is accredited by the
National Commission for Certifying Agencies (NCCA); and
• Covers the clinical and administrative duties under RCW.18.360.050(1).
National examining organizations approved by the Secretary:
a. Certied Medical Assistant Examination through the American Association of
Medical Assistants (AAMA);
b. Registered Medical Assistant Certication Examination through American
Medical Technologists (AMT);
c. Clinical Medical Assistant Certication Examination through the National
Healthcareer Association (NHA);
d. National Certied Medical Assistant Examination through the National
Center for Competency Testing (NCCT); Or,
e. Clinical Medical Assistant Certication Examination through the American
Medical Certication Association (AMCA).
Ocial score must be sent directly from the examining body directly to the
Department of Health.
F 6. Applicant’s Attestation: Required to be both signed and dated in order to
process the application.
DOH 651-028 September 2023 Page 2 of 2
Date
Stamp
Here
Name First Middle Last
Note: The mailing and email addresses you provide will be your addresses of record. It is your
responsibility to maintain current contact information on le with the department.
Country
Will documents be received in another name? F Yes F No
If yes, list name(s):
Address
City State Zip Code County
Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #)
Email address
Have you ever been known under any other name(s)? F Yes F No
If yes, list name(s):
Country
Mailing address if dierent from above address of record
City State Zip Code County
Birth date (mm/dd/yyyy)
1. Demographic Information
Please handwrite clearly in ink. It is the responsibility of the applicant to submit all supporting documentation.
Failure to do so may result in a delay in processing your application.
Revenue: 0252625081
Social Security Number (SSN)
(If you do not have a SSN, see instructions)
F Male F Female
F Prefer Not to Answer
F X
National Provider Identier Number (NPI)
(Enter 10 digit number)
DOH 651-029 September 2023 Page 1 of 3
Medical Assistant-Certied Expired Activation Application
Medical Assistant Credentialing
P.O. Box 1099
Olympia, WA 98507-1099
DOH 651-029 September 2023 Page 2 of 3
2. Other License, Certication, or Registration
State/Jurisdiction Profession
Credential
Method of
Credentialing
Currently In
Force
Type Number Year Issued
No Yes
3. Experience
Type of experience of practice and location start (mm/yyyy) end (mm/yyyy)
4. Criminal and Disciplinary Action Attestation
I certify no action has been taken by any state or federal jurisdiction or hospital, which would prevent or restrict my
right to practice my profession.
I further certify I have not voluntarily given up any credential or privilege or have not been restricted in the practice
of my profession in lieu of or to avoid formal action.
The department does criminal background checks on all applicants.
Applicant’s Initials Date (mm/dd/yyyy)
DOH 651-029 September 2023 Page 3 of 3
6. Applicant’s Attestation
I, ________________________________________ , declare under penalty of perjury under the laws of
the state of Washington that the following is true and correct:
• I am the person described and identied in this application.
• I have read RCW 18.130.170 and RCW 18.130.180 of the Uniform Disciplinary Act.
• I have answered all questions truthfully and completely.
• The documentation provided in support of my application is accurate to the best of my
knowledge.
• I have read all laws and rules related to my profession.
I understand the Department of Health may require more information before deciding on my application.
The department may independently check conviction records with state or federal databases.
I authorize the release of any les or records the department requires to process this application. This
includes information from all hospitals, educational or other organizations, my references, and past and
present employers and business and professional associates. It also includes information from federal,
state, local, or foreign government agencies.
I understand I must inform the department of any past, current or future criminal charges or
convictions. I will also inform the department of any physical or mental conditions that jeopardize my ability
to provide quality health care. If requested, I will authorize my health providers to release to the
department information on my health, including mental health and any substance abuse treatment.
Dated __________________________________ By: _______________________________________
(Original signature of applicant)
(Print applicant name clearly)
(mm/dd/yyyy)
5. Examination (Complete this section only if you have been expired within the last six months.)
Have you taken and passed one of the following exams within the last ve years? F Yes F No
Do you currently hold a national certication with one of the following organizations? F Yes F No
Please answer Yes or No and select all that apply:
F Certied medical assistant examination through American Association of Medical Assistants (AAMA)
Year passed? __________
F Registered medical assistant certication examination through American Medical Technologists (AMT)
Year passed? __________
F Clinical medical assistant certication examination through the National Healthcareer Association (NHA)
Year passed? __________
F National certied medical assistant examination through the National Center for Competency Testing (NCCT)
Year passed? __________
F Clinical Medical Assistant Certication Examination through the American Medical Certication Association
(AMCA).
Date passed (mm/dd/yyyy)? __________
F National Certication Number: _______________________________
Request ocial scores to be sent directly to the Department of Health.
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RCW/WAC and Online Website Links September 2021
RCW/WAC and Online Website Links
RCW/WAC Links
Uniform Disciplinary Act, RCW 18.130
Administrative Procedure Act, RCW 34.05
Medical Assistant Law, RCW 18.360
Medical Assistant Rules, WAC 246-827
Online
Medical Assistant, Web Page
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