EmailMe Form - Volunteer and Retired Providers License Renewal

Volunteer and Retired Providers License Renewal

Volunteer and Retired Providers License Certification

This online form serves to authorize the Washington State Department of Health to renew your healthcare license as a Volunteer and Retired Providers (VRP) Program volunteer.

Please complete the application below.*

*Please include your signed attestation found on your renewal notice. Renewals cannot be completed without this information.

Questions? Please contact either:

Washington Healthcare Access Alliance
vrp@wahealthcareaccessalliance.org

Office of Rural Health, Department of Health
ruralhealth@doh.wa.gov
360-236-2804

License Renewal Notice File Upload

Please upload your signed renewal notice noting your CE hours in either .pdf .png or .jpg format. See "Add File".

Front side of Renewal *

Add File
Back side of Renewal (if applicable)

Add File
Name
First Last
License Number including Letters: Example RN12345678 *
License Expiration Date xx/xx/xxxx format
(If renewing ARNP, provide both RN and ARNP License Number and upload active national certification)
License Expiration Date xx/xx/xxxx format
Upload active national certification (ARNPs only)

Add File
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone
### - ### - ####
Email
I am a new provider with the VRP Program requesting license renewal.
Yes
No, I am an existing member of the VRP program.
How did you hear about the VRP Program?
Volunteer services will be provided at clinic(s) that are VRP Program approved sites.
Clinic
Signature
Clear
If you are unable to sign electronically above, please upload a copy of your signature in .pdf, .png or .jpg format.
Please renew your license early! The Department of Health cannot cover any late or reissuance fees. If you have questions related to license renewal, malpractice coverage, or other support for healthcare volunteers in Washington, contact the Volunteer and Retired Providers Program at vrp@wahealthcareaccessalliance.org or submit questions in the box below.