Medical Assistant Registered Healthcare Practitioner Endorsement

Applicant:

Use this form for medical assistant-registered endorsement. All information should be printed clearly

in blue or black ink. This form may be duplicated.

An endorsement must be signed by a healthcare practitioner as dened in RCW 18.360.010.

• You may only perform the medical tasks listed in your current attestation for endorsement, as

listed in RCW 18.360.050(4). Do not add additional tasks to this form.

• A new endorsement form must be submitted within 30 days if your tasks change.

• Your endorsement is valid as long as you are continuously employed as a medical

assistant-registered by the same healthcare practitioner, clinic or group and you renew your

registration.

• Your endorsement is not transferable to another healthcare practitioner, clinic or group

practice.

Fill out section one and forward to the healthcare practitioner for completion of sections

two through four.

1. Print clearly:

Name Last First Middle

Birth Date (mm/dd/yyyy) Social Security Number

Address

City State Zip Code

2. Healthcare Practitioner:

Applicant Date of Hire: _______________________________

The above individual seeks verication of supervised medical assisting and endorsement as a

medical assistant-registered. Please complete the following:

Healthcare Practitioner (check all that apply)

F MD F DO F MD-PA F DO-PA F ARNP F RN F DPM F ND FOD

Healthcare Practitioner Name Phone (enter 10 digit #)

Healthcare Practitioner License Number License Expiration Date

Practice Setting (Check One):

F Group Practice F Clinic F Physician’s Oce F Hospital F Other Healthcare Facility

Medical Assistant Credentialing

P.O. Box 47877

Olympia, WA 98504-7877

360-236-4700

Medical Assistant-Registered

Healthcare Practitioner Endorsement

DOH 651-005 September 2023 Page 1 of 4

(mm/dd/yyyy)

3. Facility Information:

Facility Name

Facility Mailing Address

City State Zip Code

4. Healthcare Practitioner Attestation:

I______________________________________________________________________ attest that

_______________________________________________________________________ will assist

with patient care and perform administrative and clinical procedures.

I attest appropriate supervision will be provided to the medical assistant-registered in carrying out

the procedures delegated.

I attest the medical assistant-registered has demonstrated competency to perform the following

tasks:

a. Fundamental procedures:

i. Wrapping items for autoclaving .............................................................................F F

ii. Procedures for sterilizing equipment and instruments ...........................................F F

iii. Disposing of biohazardous materials .....................................................................F F

iv. Practicing standard precautions ............................................................................F F

b. Clinical procedures:

i. Preparing for sterile procedures ............................................................................F F

ii. Taking vital signs....................................................................................................F F

iii. Preparing patients for examination ........................................................................F F

iv. Observing and reporting patients’ signs or symptoms. ..........................................F F

c. Specimen collection:

i. Obtaining specimens for microbiological testing....................................................F F

ii. Instructing patients in proper technique to collect urine and fecal specimens. ......F F

iii. Finger and/or heel stick to collect a blood specimen .............................................F F

Healthcare Practitioner (print)

Medical Assistant-Registered Name (print)

Yes No

DOH 651-005 September 2023 Page 2 of 4

d. Patient care:

i. Telephone and in-person screening limited to intake and gathering

of information without requiring the exercise of judgment

based on clinical knowledge ..................................................................................F F

ii. Obtaining vital signs...............................................................................................F F

iii. Obtaining and recording patient history .................................................................F F

iv. Preparing and maintaining examination and treatment areas ...............................F F

v. Preparing patients for and assisting with routine and specialty

examinations, procedures, treatments, and minor oce surgeries, including

those with minimal sedation...................................................................................F F

vi. Maintaining medical and immunization records .....................................................F F

vii. Screening and following up on test results as directed by a

healthcare practitioner ...........................................................................................F F

e. Diagnostic testing and electrocardiography ................................................................F F

f. i. Tests waived under the federal clinical laboratory improvement (CLIA)

amendments program ............................................................................................F F

ii. Moderate complexity tests if the medical assistant-registered meets standards

for personnel qualications and responsibilities in compliance with federal

regulation for nonwaived testing.............................................................................F F

g. Administering eye drops, topical ointments, and vaccines,

including combination or multidose vaccines. .........................................................F F

h. Urethral catheterization when appropriately trained....................................................F F

i. Administering medications ..........................................................................................F F

i. A medical assistant-registered may only administer medications if the drugs are:

A. Administered only by unit or single dosage, or by a dosage calculated and veried by a

health care practitioner. A combination or multidose vaccine shall be considered a dose.

B. Limited to legend drugs, vaccines, and Schedule III through V controlled substances as

authorized by a health care practitioner under the scope of his or her license and consistent

with rules adopted by the secretary.

C. Administered pursuant to a written order from a health care practitioner.

ii. A medical assistant-registered may only administer medication for intramuscular injections

for diagnostic or therapeutic agents under the immediate supervision of a health care

practitioner who is to be on the same premises.

j. Telemedicine supervisor.............................................................................................. F F

A medical assistant may be supervised by a health care practitioner through telemedicine

supervision during a telemedicine visit. Tasks assigned to the medical assistant by a health

care practitioner providing telemedicine supervision must fall within the medical assistant’s

legal scope of practice.

DOH 651-005 September 2023 Page 3 of 4

A medical assistant providing direct patient care under telemedicine supervision is subject to this

section if no other health care practitioner is physically present and immediately available in the

place where the medical assistant and patient are located.

See WAC 246-827-0140 Telemedicine supervision—Activities allowed or prohibited.

I attest that the above information is accurate and complete to the best of my knowledge.

I understand that the Department of Health may request additional information, if it is needed.

_____________________________________ ______________________________________

Original Signature—Healthcare practitioner

Original Signature—Medical Assistant-Registered

Date (mm/dd/yyyy)

DOH 651-005 September 2023 Page 4 of 4