DOH 657-135 September 2021
Limited Physician and Surgeon Clinical Experience
License Application Packet
Contents:
1. 657-135 ...Contents List/SSN Information/Mailing information ...........................1 page
2. 657-136 ...Application Instructions Checklist ....................................................2 pages
3. 657-137 ...License Requirements.....................................................................2 pages
4. 657-138 ...Limited Physician and Surgeon Application ....................................5 pages
6. 657-099 ...Malpractice / Liability History Form ...................................................1 page
8. 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 your
check or money order payable to: Send additional documents to:
Department of Health Washington Medical Commission
P.O. Box 1099 P.O. Box 47866
Olympia, WA 98507-1099 Olympia, WA 98504-7866
Contact us:
360-236-2750
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.
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DOH 657-136 September 2021 Page 1 of 2
Important background check Information: Washington State law authorizes the
Department of Health to obtain ngerprint-based background checks for licensing
purposes. This check may be through the Washington State Patrol and the Federal
Bureau of Investigation (FBI). This may be required if you have lived in another state or
if 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 to
submit the correct forms required.
F Application Fee. (This fee is non-refundable). You can check the online fee page
for current fees.
F Select if the following applies:
Spouse or Registered Domestic Partner of Military Personnel
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 Identier Number (NPI): The National Provider Identier (NPI)
is a standard unique identier for health care professionals available from the
Federal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric
identier. If you have a NPI number, provide this on your application.
Legal Name: List your full name: rst, middle, and last.
Denition of legal name: “Legal name” is the name appearing on your ocial
certicate of birth or, if your name has changed since birth, on an ocial marriage
certicate 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 when you were born.
Address: List the address we should use to send any information on 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 notied
of a change. See WAC 246-12-310.
Phone Cell Numbers: Enter your phone and cell numbers, if applicable.
Email: Enter your email address, if applicable.
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.
Application Instructions Checklist
DOH 657-136 September 2021 Page 2 of 2
F 2. Personal Data Questions:
All applicants must answer the same personal data questions. They are focused on
your tness to practice the essential skills of this profession.
If you answer “yes” to any questions in this section, you must provide an
appropriate explanation. You must also provide the documentation listed in the note
after the question. If you do not provide this, your application is incomplete and it
will not be considered.
• Question 3 includes misdemeanors, gross misdemeanors and felonies. You do
not have to answer yes if you have been cited for trac infractions. You can get
copies of court records through the county courthouse where the conviction,
plea, deferred sentence, or suspended sentence was entered.
• “Another jurisdiction” means any other country, state, federal territory, or military
authority.
F 3. Education:
List in chronological order your medical school education.
F 4. Medical Specialty:
List the Medical Specialty in which you were trained and/or practiced in outside
of the United States. This should coincide with the specialty you will be practicing
within the scope of practice with your primary supervisor.
F 5. Applicant’s Attestation:
You must sign and date this for us to process the application. Please read
thoroughly to ensure your understanding of the provisions in this section.
Federation Credentials Verication Services (FCVS) Verication: The Commission
accepts documents submitted by the FCVS in lieu of original primary source verication
for the following: verication of medical education, postgraduate training, examination
history, ECFMG, board action history, board certication and identity. For more
information, please visit the FCVS website.
F Medical School Transcripts:
Ocial transcripts will only be required if you are not licensed in other state or
if your Medical School is not veried on the AMA Physician Prole. If you need
to request ocial transcripts please have them sent directly from the applicant’s
medical school to this oce listing the dates of attendance, subjects completed,
degree and date awarded. They can be sent electronically from the Medical School
F Letter of Nomination:
We will need a letter of nomination sent directly from Chief Medical Ocer of any
hospital, appropriate medical practice, the Department of Children, Youth, and
Families (DCYF), the Department of Social and Health Services (DSHS), the
Department of Corrections (DOC), or a county or city health department. The letter
must state employment start date.
F Medical License Examination Requirements:
Applicants must pass all steps of the United States Medical License Examination
(USMLE).
Ocial license examination certication must be sent directly from the oce of
record. USMLE scores must be received directly from the Federation of State
Medical Boards. You can obtain the request form through their website.
F AMA and FSMB Proles:
The department sta will obtain the American Medical Association (AMA) Physician
prole report and the Federation of State Medical Boards (FSMB) data bank
clearance report. However, if sta is unable to obtain the reports electronically, the
applicant will be required to submit requests and pay any applicable fees.
F ECFMG Certication:
Educational Commission for Foreign Medical Graduates (ECFMG) Certication
must be sent directly from the ECFMG to this oce stating that the applicant
has been issued a standard certicate with an indenite status. The request for
certication can be obtained through the ECFMG’s website.
License Requirements
DOH 657-137 September 2021 Page 1 of 2
F Proof of Residence
In order to qualify for this license, applicants must be a resident in the state of
Washington for at least one year. Applicants must submit proof of residence by
providing the Commission with one of the following:
• WA State issued ID
• WA Driver’s License
• WA Voter’s Registration
F Practice Agreement
Before the Commission can grant this license, applicants must submit a practice
agreement with a supervising physician. This agreement will need to list the job
duties the applicant will be performing at the place of employment. For more
information and to submit the practice agreement, please visit the Medical
Commission’s Website.
Applicants must meet all the licensing requirements listed above to be granted a license.
The Commission does not allow completed applications to be withdrawn. Applicants
that submit a completed application and do not meet the requirements may have their
application denied by the Commission.
After the application and fees have been received by the Commission, the applicant will
be notied if any documents or data are missing as only complete applications will be
considered for review.
• Once the application is completely submitted, routine applications require 14
days for processing. Non-routine applications require more time for processing.
• All information, documents, data, etc. provided to the Commission by the
applicant will become a part of the le.
• It is the responsibility of the applicant to provide verication information in
support of the application for a physician license. Documents submitted in
support of the application must be submitted directly from the originating source.
• Applications that are pending for one year will become invalid, along with the
fee and any other supporting documentation. It will be necessary to begin the
process over with a new application, current fee, and all supporting documents.
DOH 657-137 September 2021 Page 2 of 2
DOH 657-138 September 2021 Page 1 of 5
Revenue 0252090000
Date
Stamp
Here
Background
Check
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 #) Cell (enter 10 digit #)
Employer Name
Have you ever been known under any other name(s)? F Yes F No
If yes, list name(s):
Employer Address
City State Zip Code County
Birth date (mm/dd/yyyy)
1. Demographic Information
Limited Physician and Surgeon Clinical Experience Application
F Male F Female
F Prefer Not to Answer
F X
Social Security Number (SSN)
(If you do not have a SSN, see instructions)
National Provider Identier Number (NPI)
(Enter 10 digit number)
Select if the following applies: F Spouse or Registered Domestic Partner of Military Personnel
Employer Email
Email
DOH 657-138 September 2021 Page 2 of 5
1. Do you have a medical condition which in any way currently impairs or limits your ability to practice your
profession with reasonable skill and safety?............................................................................................ F F
If yes, please attach any supporting documentation and a detailed explanation
“Medical Condition” includes physiological, medical, mental or psychological conditions or disorders, such
as, but not limited to orthopedic, visual, speech, and hearing impairments, cerebral palsy, epilepsy, sleep
disorder, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, intellectual disabilities,
emotional or mental illness, specic learning disabilities, HIV disease, tuberculosis, drug addiction, and
alcoholism.
You may answer No if the behavior or condition is already known to the Washington Physician Health
Program (WPHP). "Known to WPHP" means that you have informed WPHP of your behavior or
conditions and you are complying with all of WPHP's requirements for evaluation, treatment, and/or
monitoring.
If Yes, You must submit detailed information to the Commission that will allow the Commission
to assess your ability to practice safely, competently, and without impairment to your professional
judgment, skill, or knowledge. In addition to this information, you are required to provide copies of any
related records, reports, evaluations, police reports, probation reports, and court records directly to the
Commission.
Note: If you answered “yes” to question 1, the licensing authority will assess the nature, severity, and
the duration of the risks associated with the ongoing medical condition and the ongoing treatment to
determine whether your license should be restricted, conditions imposed, or no license issued.
The licensing authority may require you to undergo one or more mental, physical or psychological
examination(s). This would be at your own expense. By submitting this application, you give
consent to such an examination(s). You also agree the examination report(s) may be provided to the
licensing authority. You waive all claims based on condentiality or privileged communication. If you
do not submit to a required examination(s) or provide the report(s) to the licensing authority, your
application may be denied.
2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your
profession with reasonable skill and safety? If yes, please explain.......................................................... F F
“Currently” means within the past six months.
“Chemical substances” include alcohol, drugs, or medications, whether taken legally or illegally.
Note: If you answer “yes” to any of the remaining questions, provide an explanation and certied
copies of all judgments, decisions, orders, agreements and surrenders. The department does criminal
background checks on all applicants.
3. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a
sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? ..............................F F
Note: If you answered “yes” to question 3, you must send certied copies of all court documents
related to your criminal history with your application. If you do not provide the documents, your
application is incomplete and will not be considered.
To protect the public, the department considers criminal history. A criminal history may not
automatically bar you from obtaining a credential. However, failure to report criminal history may
result in extra cost to you and the application may be delayed or denied.
2. Personal Data Questions
Yes No
DOH 657-138 September 2021 Page 3 of 5
4. Have you ever been found in any civil, administrative or criminal proceeding to have:
a. Possessed, used, prescribed for use, or distributed controlled substances or legend
drugs in any way other than for legitimate or therapeutic purposes? .................................................F F
b. Diverted controlled substances or legend drugs? ................................................................................F F
c. Violated any drug law? .........................................................................................................................F F
d. Prescribed controlled substances for yourself? ....................................................................................F F
5. Have you ever been found in any proceeding to have violated any state or federal law or rule
regulating the practice of a health care profession? If “yes”, please attach an explanation and
provide copies of all judgments, decisions, and agreements? .................................................................F F
6. Have you ever had any license, certicate, registration or other privilege to practice a health care
profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? ..............F F
7. Have you ever surrendered a credential like those listed in number 6, in connection with or to
avoid action by a state, federal, or foreign authority? ...............................................................................F F
8. Have you ever been named in any civil suit or suered any civil judgment for incompetence,
negligence, or malpractice in connection with the practice of a health care profession? .........................F F
9. Have you ever had hospital privileges, medical society, other professional society or organization
membership revoked, suspended, restricted or denied? .......................................................................... F F
10. Have you ever been the subject of any informal or formal disciplinary action related to the practice
of medicine?. ............................................................................................................................................F F
11. To the best of your knowledge, are you the subject of an investigation by any licensing board as to
the date of this application?. .....................................................................................................................F F
12. Have you ever agreed to restrict, surrender, or resign your practice in lieu of or to avoid adverse
action?. .....................................................................................................................................................F F
13. Have you ever been disqualied from working with vulnerable persons by the
Department of Social and Health Services (DSHS)? ...............................................................................F F
2. Personal Data Questions (Cont.)
Yes No
Schools attended (Location if other than U.S., quote names of
schools in original language and translate to English.)
3. Education
End
mm/yyyy
Dates Attended
List all Medical School Education
Date of
Graduation
mm/dd/yyyy
Diploma or degree obtained
(Quote titles in original language
and translate to English.)
Medical education (list all medical schools attended)
DOH 657-138 September 2021 Page 4 of 5
Start
mm/yyyy
4. Medical Specialty
What did you train/practice in outside of the US?
DOH 657-138 September 2021 Page 5 of 5
5. 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 identied 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 that 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 ___________________________ at _____________________________________________
By: _______________________________
(Signature of applicant)
(Print applicant name clearly)
(City, state)(mm/dd/yyyy)
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DOH 657-099 September 2021
Malpractice / Liability History
Applicant’s name: __________________________________________________ Today’s date: _______________
Please submit a form for each past or current professional liability claim or lawsuit which has been led against
you. Photocopy this page as needed. Only a legible and signed narrative which addresses all of the following
details will be accepted.
1. Provide a detailed summary of the events of the case. Include the date of occurrence, your specic
involvement, and the patient’s clinical outcome. Please submit additional pages of narrative if necessary.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Date of occurrence: ______________________Details: ___________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
2. Date suit or claim was led: ________________________
Name and address of insurance carrier that handled the claim: ______________________________________
________________________________________________________________________________________
3. Your status in the legal action (primary defendant, codefendant, other):
4. Current status of suit or other action:
5. Date of settlement, judgment, or dismissal:
6. If the case was settled out of court, or with a judgment, settlement amount paid on your behalf, please
disclose the amount.
You must enclose a copy of nal disposition of case this includes dismissals. $ _______________
I verify the information contained in this form is correct and complete to the best of my knowledge:
Signature _________________________________________________________Date ______________________
Washington Medical Commission
P.O. Box 47866
Olympia, WA 98504-7866
360-236-2750
MDCE
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RCW/WAC Links
Uniform Disciplinary Act, UDA RCW 18.130
Administrative Procedure Act, APA RCW 34.05
Administrative procedures and requirements, WAC 246-12
Physician, RCW 18.71
Address changes. It is the responsibility of each practitioner to maintain his or her
current address on le with the department. Requests for address changes must be
made in writing. The mailing address on le with the department will be used for mailing
of all ocial matters to the practitioner. See WAC 246-12-310.
Online
Washington Medical Commission Web Page
RCW/WAC and Online Website Links
RCW/WAC and Online Website Links September 2021
