Get Wa 010207 2021-2024

010207 08-2016 Race/Ethnicity/Language Supplemental Information Providing this information is voluntary The information is to help us meet the cultural and linguistic needs of our members so they can find practitioners that speak the same language or have the same cultural background. Practitioner Application To use the Practitioner Application follow these instructions Keep an unsigned and undated copy of the application on file for future requests. When a request is received send a copy of the completed application making sure that all information is complete current and accurate. Please sign and date pages 11 and 13. Please document any YES responses on the Attestation Question page. Identify the health care related organization s to which this application is being submitted in the space provided below. Attach copies of requested documents each time the application is submitted* If changes must be made to the completed application strike out the information and write in the modification initial and date. If a section does not apply to you please check the provided box at the top of the section* Expect addendums from the requesting organizations for information not included on the application* This application is submitted to 1. INSTRUCTIONS This form should be typed or legibly printed in black or blue ink. If more space is needed than provided on original attach additional sheets and reference the question being answered* Please do not use abbreviations. Current copies of the following documents must be submitted with this application all are required for MDs DOs as applicable for other health practitioners. DEA Certificate Curriculum Vitae Not an acceptable substitute for completing the application* Dates need to be listed in Face Sheet of Professional Liability Policy or Certificate mm/yyyy Format All sections must be completed in their entirety. 2. PRACTITIONER INFORMATION Legal Name Required Last Name include suffix Jr. Sr. III First Middle Degree s List any other name s under which you have been known by reference licensing and or educational institutions Home Mailing Address City State Home Telephone Number Pager Number Birth Date mm/dd/yyyy Birth Place city state country Social Security Number Male Have you ever voluntarily opted-out of Medicare Yes NPI Medicare Number Specialty primarily practicing Cell Phone Number Female Zip Code E-Mail Address Citizenship Languages Fluently Spoken by Practitioner No Medicaid DSHS Number s L I Number s Sub specialties primarily practicing Other Professional Interests in Practice Research etc* Page 1 of 13 -1Modification to the wording or format of the Practitioner Application may invalidate the application* 3. PRACTICE INFORMATION CHECK ALL THAT APPLY Effective Date at Primary Practice location MM/YY Practice Setting Clinic/Group Solo Practice Home Based Hospital Based Primary Care Site Urgent Care Other Practitioner Profile PCP Specialist Check if you are both PCP OB OB in your practice Yes No Deliveries Name of Practice / Affiliation or Clinic Name Department Name if hospital based Primary Office Street Address Patient Appointment Telephone Number Mailing Address if different from above Org* NPI Fax Number Practice Website Office Manager / Administrator Name Administration Telephone Number Credentialing Contact if different from above Telephone Number Federal Tax ID Number Name Affiliated with Tax ID Number Is the office wheelchair accessible Office Hours Are you accepting new patients Have you limited your practice in any way e*g* 18 years or older No If yes please explain Do you currently supervise ARNP s or PA s Yes If yes please provide the name and specialty below Please list languages fluently spoken by office staff A.