EmailMe Form - Volunteer and Retired Providers License Renewal

License Renewal Notice File Upload

Please upload your signed and dated renewal notice if you receive a paper form or attest to CE hours below. Please use .jpg format. See "Add File".

Signed and dated DOH paper renewal notice if applicable

Name

First Last

License Number including Letters: Example RN12345678 *

License Expiration Date xx/xx/xxxx format

I certify that during the time that this license is in effect:

• I will not receive remuneration for the practice of health care, either as an independent practitioner or as an employee at this clinic or any other clinic.

• I will provide care to all patients, regardless of their ability to pay.

• My health care services are limited to:
- Non-invasive care services, see RCW 43.70.470, and;

- Obstetric care is not available with this program.

• I certify that I have completed all continuing education/competency required for my license renewal and will furnish documentation upon request.

Number of continuing education/competency hours completed:

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

(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)

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.