DOH 657-125 August 2018
Limited Physician and Surgeons Application Packet
Contents:
1. 657-125 ......Contents List/SSN Information/Mailing information ................... 1 page
2. 657-111 .......Application Instructions Checklist ............................................ 4 pages
3. 657-117 ....... Social Security Number Notication .......................................... 1 page
4. 657-056 ......Limited Physician and Surgeon Application ............................ 6 pages
5. 657-099 ......Malpractice / Liability History ..................................................... 1 page
6. 657-093 ......Request for Medical School Transcripts .................................... 1 page
7. 657-121 ......Postgraduate Training Program Director
Verication and Evaluation of Training ...................................... 1 page
8. 657-122 ......Medical Licensing Board Verication ......................................... 1 page
9. 657-123 ......Hospital Privileges Verication .................................................. 1 page
10. 657-057 ......Resident Physician Limited License Form ................................ 1 page
11. RCW/WAC and Online Web Site Links ......................................................... 1 page
Important Social Security Number Information:
You are required by state and federal law to provide a social security number with your
application. If you do not have a social security number at the time you send in this
application, please complete the Social Security Number Notication.
A U.S. Individual Taxpayer Identication Number (ITIN) or a Canadian Social Insurance
Number (SIN) cannot be substituted.
In order to process your request:
Mail only your application with
your check or money order payable to: Send additional documents to:
Department of Health Medical Quality Assurance Commission
P.O. Box 1099 P.O. Box 47866
Olympia, WA 98507-1099 Olympia, WA 98504-7866
Contact us:
360-236-2750
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DOH 657-111 August 2018 Page 1 of 4
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. It is your responsibility to submit the correct
forms required.
F Application Fee. (This fee is non-refundable). You can check the 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. Please complete the Social Security Number Notication 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.
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 of your birth.
Birth place: Provide the city, state, and country where 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, Fax, and Cell Numbers: Enter your phone, fax, 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 657-111 August 2018 Page 2 of 4
F Institution or Training Program Information:
List the name of the institution or training program and the address.
Required you must provide this information to become licensed.
• Physicians with a limited license may not change their institution address.
Only the program may submit evidence of a program address change.
F Medical Specialty:
List medical school, year of graduation, and medical specialty.
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. Medical Education and Postgraduate Training:
List in chronological order your medical school education. Verify all postgraduate
training received in the United States or Canada. Verication must be completed
by the program director with beginning and ending dates and sent directly to the
Medical Commission.
F 4. Professional Experience:
List in chronological order any professional experiences you have had since
medical school. A Curriculum Vitae or resume will not be accepted in lieu of
completing this section of the application. If you need more space, attach a piece of
paper.
F 5. Hospital Privileges Verication:
Excluding postgraduate training hospital privileges:
Do not list any postgraduate training hospital privileges. If you had independent
hospital privileges outside of a training program, please request all hospital
privileges granted in the past ve years veried and sent directly to this department.
Forms provided.
F 6. Licenses in Other States:
List in chronological order all licenses to practice medicine in any state, territory,
Canadian province or other country. Include active, inactive, temporary and training
licenses. Please provide verication directly from the state(s) that you have listed in
this section.
F 7. AIDS Education and Training Attestation:
AIDS adavit must be initialed and dated. AIDS training may include self-study,
direct patient care, courses, or formal training, required by WAC 246-12-260 course
content can be found at WAC 246-12-270.
F 8. Applicant’s Photograph:
Attach a current photograph, taken within the last year, in the box provided or
attach to the application. Indicate the date the photograph was taken. Sign in ink
across the bottom of the photo. The photograph must be a clear, close up, with a
front view of applicant.
F 9. Applicant’s Attestation:
You must sign and date this for us to process the application.
For Spouses and Registered Domestic Partners of Military
Personnel Being Transferred or Stationed in Washington:
Under state law, if you are the spouse or state-registered domestic partner of a
servicemember of any branch of the U.S. Military, to include Guard or Reserve, and
are applying for a health care professional credential in this state, you may be eligible
to have the processing of your application expedited to receive your credential more
quickly.
Documents to submit with your application should include the following:
• A copy of your spouse’s or registered domestic partner’s military transfer orders
to Washington State.
• One of the following:
- A copy of your marriage certicate to show proof of marriage; or
- A copy of a state’s declaration or registration showing you are in a state
registered domestic partnership with a member of the U.S. military.
DOH 657-077 August 2018 Page 3 of 4
DOH 657-077 August 2018 Page 4 of 4
Limited Licenses Categories with specic requirements
Resident Physician Limited License:
F Includes interns and medical residents and fellows.
F The program must submit a residency certication form stating the beginning date
of the program. The document must be original and submitted directly to this oce
by the program.
Fellowship or Teaching/Research Limited License
F A letter of nomination from the dean of the medical school at the University of
Washington or chief executive of hospital or other appropriate health care facility
licensed in the state of Washington. The letter must state the program start date.
F License verication from state or country of origin—state license verication must
be original and received direct from licensing entity; licenses from country of origin
may be a notarized copy of original license documents. A fellowship license has a
limit of two years total.
Institutions or County-City Health Department Limited License:
F Original letter verifying employment received directly from ocial department. The
letter must state employment start date.
F License verication from state or country of origin—state license verication must
be original and received direct from licensing entity. Licenses from country of origin
may be a notarized copy of original license documents.
Note: A limited license is only for practicing medicine within the limitation of the specic
training program or institution or county-city department.
All application documentation required:
Malpractice: (if applicable) All medical malpractice law suits you have been named in
must be reported and should include the nature of the case, date and summary of care
given on the professional liability form provided. The applicant must also include copies
of the settlement or nal disposition. If pending, indicate status.
Transcripts: All medical school transcripts must list the dates of attendance, subject
completed, degree and date awarded and sent directly to this oce.
• Exception: A letter of verication from the dean of medical school will be
accepted for a limited license; however, a copy of the ocial transcripts must be
submitted. (Form provided)
• Foreign Transcripts: Foreign medical school transcripts must list the dates of
attendance, subjects completed; degree and date awarded and be sent directly
to this oce. All documentation must be translated to English. All translations
must be original documents with the appropriate signatures and seals.
FSMB Data Bank Clearance and the AMA Physician Prole (Only those who
have completed prior training in the U.S.): The Federation of State Medical Boards
data bank clearance and the American Medical Physician Program will be obtained
electronically by Department sta. If sta is unable to obtain either report, the applicant
is responsible to obtain the reports and pay the necessary fees.
Social Security Number Notication
I have not provided a social security number for the following reason:
F I do not have a social security number, and when I applied for one, it was denied.
(Attach any correspondence received from the Social Security Administration.)
F I do not have a social security number, but I have an individual taxpayer
identication number, which is _________________________________________.
F I am a foreign national with a student visa only and do not qualify for a social
security number because of that visa status.
F I will be in the United States on a visa and cannot apply for a social security number
until my visa has been approved and I have entered the United States.
F I do not have a social security number, and when I applied for one, it was denied.
F Other (Provide a detailed explanation)
______________________________________________________________
______________________________________________________________
______________________________________________________________
I declare under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
__________________________________ __________________________________
__________________________________
__________________________________
DOH 657-117 August 2018
Place Signed
Date Signed
SignaturePrinted Name
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Revenue 0252140000
Date
Stamp
Here
Background
Check
Stamp
Here
DOH 657-056 August 2018 Page 1 of 6
Name First Middle Last
1. Demographic Information
Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #)
Address
Email Address:
Birth date (mm/dd/yyyy)
City State Country
Will documents be received in another name? If yes, list name(s):
Have you ever been known under any other name(s)? If yes, list name(s):
Institution or Training Program Information (Required)
Institution/Program Name
Institution/Program Mailing Address
Limited Physician & Surgeons License Application
F Resident Physician F Teaching/Research F Institutional
F Fellowship (2 year limit) F County/City Health Department
Place of Birth
City
State
Zip Code
County
City State Zip Code County
Medical Speciality
Medical school
Medical Specialty
F Male
F Female
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
Please provide the institution or training program in WA that you will be participating in.
DOH 657-056 August 2018 Page 2 of 6
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 657-056 August 2018 Page 3 of 6
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
DOH 657-056 August 2018 Page 4 of 6
Schools attended (Location if other than U.S., quote names
of schools in original language and translate to English.)
3. Education
Dates granted
List all Medical School Education
Number
of years
attended
Diploma or degree obtained
(Quote titles in original language
and translate to English.)
Medical education (list all medical schools attended)
Postgraduate training (list all programs attended)
Start
(mm/yyyy)
End
(mm/yyyy)
4. Professional Experience
In date order, most recent to later, list all professional experience received since graduation to the present. Exclude
activities listed under other sections, identify any periods of time break of 30 days or more.
Name and location of institution
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
Nature of experience or specialty
5. Hospital Privileges Verication
Excluding postgraduate training, list hospitals where all privileges that have been granted within the past ve years.
If you need more space, attach a piece of paper.
Name of hospital
Dates attended
Start Date
(mm/dd/yyyy)
End Date
(mm/dd/yyyy)
DOH 657-056 August 2018 Page 5 of 6
7. AIDS Education and Training Attestation
I certify that I have completed a minimum of four hours of education in the prevention, transmission, and
treatment of AIDS. This education included topics of etiology and epidemiology, testing and counseling, infection
control guidelines, clinical manifestations and treatment, legal and ethical issues to include condentiality, and
psychosocial issues to include special population considerations.
Applicant’s initials Date
Attach current photograph here.
Indicate date taken and sign in
ink across bottom of the photo.
NOTE: Photograph must be:
1. Original, not a photocopy
2. No larger than 2” X 2”
3. Taken within one year of
application
4. Close up, front view of applicant
Photo Here
⌂
8. Applicant’s Photograph
Height
Weight
Hair color
Color of eyes
Signature ___________________________________________
Date of Photo _______________________________________
6. Licenses in Other States
List all licenses to practice medicine in any state, territory, Canadian province or other country. Include active,
inactive, temporary and training licenses. Please provide verication directly from the state(s) that you have listed
in this section.
State
Date license
issued
License
Number
Status of license
Any limitations on license
F No F Yes
F No F Yes
F No F Yes
F No F Yes
F No F Yes
F No F Yes
9. 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 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)
DOH 657-056 August 2018 Page 6 of 6
(city, state)
DOH 657-099 August 2018
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 ______________________
LMT
Medical Quality Assurance Commission
P.O. Box 47866
Olympia, WA 98504-7866
360-236-2750
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____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
DOH 657-093 August 2018
University Medical School
Address
Request for Medical School Transcripts
I am applying for license to practice medicine in the state of Washington. Please send a copy
of my medical school transcripts (with the MD degree and date granted posted) directly to the
Washington State Medical Quality Assurance Commission at the address below. Thank you for
your assistance.
Department of Health
Medical Quality Assurance Commission
P.O. Box 47866
Olympia, WA 98504-7866
I authorize release of my medical school transcripts to be sent to Department of Health
____________________________________________________________________________
Signature Date
Note: If a transcript is not yet available, submit a letter of degree conrmation.
Applicant: Please complete the identifying information below to assist the registrar’s
oce in processing your request.
Student name_______________________________________________________
Social Security Number _______________________________________________
Year of graduation ________________ Birth date________________________
LMT
Medical Quality Assurance Commission
P.O. Box 47866
Olympia, WA 98504-7866
360-236-2750
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1. ___________________________________________________ is or was engaged in postgraduate training in our
program____________________________________________________________________________________
from Beginning date (month/year) ___________________ to Ending date (month/year) _____________________
in the eld of ________________________________________________________________________________
2. At the time this individual was in training, was this program accredited through the accreditation council for
graduate medical education, the Royal College of Physicians and Surgeons, or the college of family
Physicians of Canada? F Yes F No
If no, does this program qualify the applicant to become board certied? F Yes F No
3. Was the participant ever placed on probation, restricted, suspended, terminated or requested to
voluntarily resign his/her participation in the program? F Yes F No
If yes, please explain _____________________________________________________________________
4. Did this applicant successfully complete this training program? F Yes F No
F in process OR F expected date of completion ______________________
Signature ___________________________________________________________
Title _______________________________________________________________
Email ______________________________________________________________
Address ____________________________________________________________
___________________________________________________________________
Date _________________________ Phone ___________ ____________________
LMT
DOH 657-121 August 2018
(SEAL)
Applicant Name (Print or type)
Facility name __________________________________________________________________________________
Address ______________________________________________________________________________________
I am applying for a license to practice medicine in the state of Washington and before my application can be reviewed,
a verication and evaluation of the postgraduate training performed in your institution is required. I am authorizing the
release of and would appreciate you providing the information and returning it, at your earliest convenience, directly
to the address shown below. All questions must be answered.
Applicant Name (Print or type)
Signature of applicant
Birth date (mm/dd/yyyy)
Return to address listed above
To be completed by the applicant:
Medical Quality Assurance Commission
P.O. Box 47866
Olympia, WA 98504-7866
360-236-2750
Postgraduate Training Program Director
Verication and Evaluation of Training
To be completed by the facility/agency/program:
(This page intentionally left blank.)
This is to verify that ______________________________________________________ was issued license
number _______________________________________________ on __________________________________
Signature _________________________________________________
Title _____________________________________________________
Email ____________________________________________________
State Medical Board ________________________________________
Address __________________________________________________
_______________________________________________________
Date ______________________ phone ________________________
LMT
DOH 657-122 August 2018
(SEAL)
Applicant Name (Print or type)
Name of State Medical Board ______________________________________________________________________
Address _______________________________________________________________________________________
______________________________________________________________________________________________
I am applying for a license to practice medicine as a physician and surgeon in the state of Washington and before my
application can be reviewed, a verication of my license status in your state is required. I am authorizing the release
of and would appreciate you providing the information and returning it, at your earliest convenience, directly to the
address shown above. All questions must be answered.
Applicant Name (Print or type)
Signature of applicant
Birth date (mm/dd/yyyy)
1. Date license, registration, or certication expires ____________________________
2. Have any complaints been lodged against the license? F Yes F No
3. Is there currently any investigation in process regarding the license? F Yes F No
4. Has any disciplinary activity taken place regarding the license? F Yes F No
If yes, please provide any information or documentation which may be released; i.e., charges and nal disposition.
Return to address listed above.
(mm/dd/yyyy)
Medical Quality Assurance Commission
P.O. Box 47866
Olympia, WA 98504-7866
360-236-2750
Medical Licensing Board Verication
To be completed by the applicant:
To be completed by the facility/agency/program:
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1. ______________________________________________________ has/had admitting or specialty privileges at
this hospital from _________________________________ to ___________________________________.
2. Have those privileges ever been restricted, suspended or revoked by the medical sta or administration?
F Yes F No If yes, please explain __________________________________________________________
_________________________________________________________________________________________
3. Has the applicant ever been asked to resign? F Yes F No If yes, please explain ____________________
_________________________________________________________________________________________
4. Did the applicant ever resign in lieu of or to avoid adverse action? F Yes F No If yes, please explain
________________________________________________________________________________________
5. Has a report concerning the applicant ever been sent to the National Practitioner Data Bank or the Health Care
Integrity and Protection Data Bank by this hospital? F Yes F No
LMT
DOH 657-123 August 2018
(SEAL)
Applicant Name (Print or type)
Hospital Name _________________________________________________________________
Address _______________________________________________________________________________________
I am applying for a license to practice medicine in the state of Washington and before my application can be reviewed,
a verication of my employment, with evaluations, is required. I am authorizing the release of and would appreciate
you providing the information directly to the address shown above at your earliest convenience. All questions must
be answered.
Applicant Name (Print or type)
Signature of applicant
Birth date (mm/dd/yyyy)
Return to address listed above.
(mm/yyyy)(mm/yyyy)
Medical Quality Assurance Commission
P.O. Box 47866
Olympia, WA 98504-7866
360-236-2750
Hospital Privileges Verication
(Excluding postgraduate training hospital privileges)
To be completed by the applicant:
To be completed by the facility/agency/program:
Signature _________________________________________________
Title _____________________________________________________
Email ____________________________________________________
Address __________________________________________________
_______________________________________________________
Date ______________________ phone ________________________
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This certies the appointment of the following individual who is being recommended for a limited
license in Washington State.
Name of Resident Physician* _______________________________________________________
Name of training program/specialty __________________________________________________
Name of sponsoring institution ______________________________________________________
Beginning date____________________________________
Signature ________________________________________
Is this an ACGME Program? ......................................................................... Yes F No F
* Resident physician means an individual who has graduated from a school of medicine which
meets the requirements set forth in RCW 18.71.055 and is serving a period of postgraduate clinical
medical training sponsored by a college or university in this state or by a hospital accredited by this
state. The term shall include individuals designated as intern or medical fellow.
Note: The issuance of a limited license does not allow the individual to engage in the
practice of medicine outside the supervision of the postgraduate clinical medical
training program.
mm/dd/yyyy
Director of Program
Resident Physician Limited License
DOH 657-057 August 2018
LMT
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Health Professions Reference Numbers and Links
DOH RCW/WAC August 2018
RCW/WAC Links
Uniform Disciplinary Act, RCW 18.130
Administrative Procedure Act, RCW 34.05
Administrative Procedures and Requirements, WAC 246-12
Physician Laws, RCW 18.71
Physician Rules, WAC 246-919
Continuing Education
Physician Continuing Education Rules, WAC 246-919-460
Online
Medical Quality Assurance Commission Web Page
