Submit your completed form and any additional documentation by email to hsqacredentialingintake@doh.wa.gov or by mail to Department of Health, PO Box 47877, Olympia WA 98504-7877. For questions or assistance, contact the customer service center at 360-236-4700 or hsqa.csc@doh.wa.gov. Ensure all required fields are completed and all necessary documents are included to avoid delays in processing.

There are no specific important dates for this form in 2024 and 2025. However, applicants should ensure timely submission of their forms to avoid any delays in processing.

The purpose of this form is to facilitate the online application process for Nursing Assistant Registration with the Washington State Department of Health. The form provides detailed instructions, background check information, and a checklist of required documentation. It aims to streamline the application process and ensure applicants provide all necessary information for timely processing.

• 1. Social Security Number: A valid social security number is required to apply online.
• 2. Legal Name: Provide your full legal name, including first, middle, and last names.
• 3. Birth date: Enter your birth date including the month, day, and year.
• 4. Birth place: Indicate the city, state, and country where you were born.
• 5. Address: List the address where you want to receive information about your credential.
• 6. Phone, Fax, and Cell Numbers: Include your phone, fax, and cell numbers with area codes.
• 7. Other Name(s): Specify any other names you are known by or have used in the past.
• 8. Other Licenses, Certifications, or Registrations: Indicate if you have held any other licenses, certifications, or registrations in another state.
• 9. Personal Data Questions: Answer all personal data questions. If any answers are 'yes', submit a paper application.
• 10. Military Information: Provide details about any military training or spousal status for expedited processing.
• 11. National Provider Identifier Number: Provide your NPI number if you have one.
• 12. AIDS Education and Training Attestation: Confirm completion of the required AIDS education and training.
• 13. Applicant's Attestation: Agree to the applicant's attestation to continue with the application.

Failure to submit this form may result in delays in processing your application. Ensure all information is complete and accurate to avoid any issues.

• Delayed Processing: Incomplete submissions can cause delays in the processing of your application.
• Missing Documentation: Failure to provide required documentation may result in a rejected application.
• Invalid Information: Submitting inaccurate information can lead to application denial.

• 1. Initial Application: Use this form for your initial Nursing Assistant Registration application.
• 2. Credential Renewal: Complete this form to renew your Nursing Assistant credential.
• 3. Information Update: Use this form to update your personal or demographic information with the Department of Health.
• 4. Military Expedited Processing: Submit this form for expedited processing if you are military personnel or a spouse of military personnel.
• 5. Out-of-State Verification: Use this form to verify credentials from other states.