DOH 663-032 November 2021
Osteopathic Physician and Surgeon License
Application Packet
Contents:
1. 663-032 .... Contents List/SSN Information/Mailing information ...................1 page
2. 663-063 .... Application Instructions Checklist ............................................3 pages
3. 663-035 .... License Requirements .............................................................4 pages
4. 663-001 .... Osteopathic Medicine and Surgery License Application .......... 5 pages
5. 663-036 .... Training Appointment Verication ..............................................1 page
6. 663-038 .... State License Investigative Letter ..............................................1 page
7. RCW/WAC and Online Website Links .........................................................1 page
Important Social Security Number Information:
If you have a Social Security Number, the law requires you to disclose it on your
application for a professional or occupational license. 42 U.S.C. § 666(a)(13); RCW
26.23.150. It will be used under the state’s child support enforcement program to locate
individuals for purposes of establishing paternity and establishing, modifying, and
enforcing support obligations. You are not required to have or obtain a Social Security
Number to apply for or obtain a license from the Department of Health. If you do not
have a Social Security Number, you are still eligible to apply for and obtain a credential
if you meet the requirements. Please see the Declaration of No Social Security Number
Form. Please call the Customer Service Center at 360-236-4700 if you have questions.
In order to process your request:
Mail your application with Initial
documentation and your check Send other documents not sent
or money order payable to: with initial application to:
Department of Health Osteopathic Credentialing
P.O. Box 1099 P.O. Box 47877
Olympia, WA 98507-1099 Olympia, WA 98504-7877
Contact us:
360-236-4700
To request this document in another format, call 1-800-525-0127. Deaf or hard of
hearing customers, please call 711 (Washington Relay) or email civil.rights@doh.
wa.gov.
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DOH 663-063 November 2021 Page 1 of 3
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 in blue or black ink. It is your responsibility to
submit the required forms.
F Application Fee. This fee is non-refundable. You can check the online 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. You are not required to have or obtain a Social Security Number to apply
for or obtain a license from the Department of Health. Please see the Declaration of
No Social Security Number Form. Please call the Customer Service Center at 360-
236-4700 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: rst, middle, and last.
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.
Address: List the address we should use to send any information about your
license. Be sure to include the city, state, zip code, county, and country. This will be
your permanent address with the 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 you
have them.
Email: Enter your email address, if you have one.
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
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 5 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.
• If you have been granted certicate(s) of restoration of opportunity, please
provide a certied copy of each certicate.
• Another jurisdiction means any other country, state, federal territory, or military
authority.
F 3. Osteopathic Medical Education and Post Graduate Training:
Verify one year of accredited post-graduate training received in the United States.
The Department of Health will verify post-graduate training with the AOIA report. If
for any reason this information is not available with AOIA, you will be required to
have your program director send verication to this oce, including beginning and
ending dates.
F 4. Experience:
List in date order, most recent to later, all your professional experience and practice
from date of graduation from professional college. Attach additional completed
pages if you need more space.
F 5. Other License, Certication, or Registration:
List all states where credentials are or were held. Attach additional pages if you
need more space.
F 6. 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.
DOH 663-063 November 2021 Page 2 of 3
• 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 663-063 November 2021 Page 3 of 3
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To qualify for a license to practice osteopathic medicine and surgery in the state of
Washington you must have:
F Graduated from a college or school of osteopathic medicine accredited by
the American Osteopathic Association Commission on Osteopathic College
Accreditation. Provide ocial osteopathic school transcripts indicating osteopathic
doctorate degree.
F Satisfactorily completed a nationally approved one-year internship program or
the rst year of a residency program approved by the American Osteopathic
Association, the American Medical Association or by their recognized aliate
residency accrediting organizations.
F Verication of one year of accredited post-graduate training, including internships,
residencies, and fellowships. If the Department of Health is unable to verify your
post-graduate training with the AOIA report, you will be required to have your
program director submit proof of the post-graduate training, to include the beginning
and ending dates of the training.
F Completed an examination approved by the Osteopathic Medicine and Surgery
Board. See Examinations Accepted for Endorsement and State Examination.
Provide verication of a qualifying examination. See “Examinations Accepted for
Endorsement and State Examination”.
F Verication letters from all states where you have been issued a license, whether
active or inactive. This includes training licenses.
Temporary Permits
A valid license is required to practice osteopathic medicine and surgery in the state of
Washington. A one-time temporary permit may be issued for 180 days if:
• You have a license in another state that has equivalent licensing standards to
Washington State.
• You have no disciplinary history in any state or any “Yes” answers to the
Personal Data Questions.
• You have applied for a full license.
The temporary permit is intended for you to be able to begin work while waiting for
issuance of your full license. You must submit the following to be considered for a
temporary permit:
F Completed application, endorsement (NBOME only) and temporary permit
application fees. You can check the online fee page for current fees.
F Documentation from the other state where its licensing standards are equivalent to
those of Washington State.
DOH 663-035 November 2021 Page 1 of 4
License Requirements
F Verication of all state licenses, whether active or inactive, indicating you are not
subject to disciplinary charges or that disciplinary action has not been taken against
your license for unprofessional conduct or impairment.
Note: Verication of equivalency standards from the other state may take longer than
it takes to complete the full license application process. Depending on how long
it takes to get your documents listed below, you may not benet by applying for
the temporary license. Fees are nonrefundable.
Examinations Accepted for Endorsement Applications:
• Parts I, II, and III examination given by the National Board of Osteopathic
Medical Examiners or Level 1, Level 2 CE and/or Level 2 PE, and Level 3 of the
COMLEX.
Contact: National Board of Osteopathic Medical Examiners, Inc., 8765 W. Higgins Rd,
Suite 200, Chicago, IL 60631-4101
Telephone 773-714-0622
Online: http://www.nbome.org/
Email: Candidate [email protected]
• FLEX examination taken prior to June 1985. Passed with a FLEX weighted
average of at least 75 percent.
• FLEX I and FLEX II examinations with a minimum score of 75 on each
component.
• USMLE Steps 1, 2, and 3 with a minimum score as established by the testing
agencies.
If your endorsement exam is the FLEX, FLEX I and II, or the USMLE exam, you will also
be required to pass the Washington Osteopathic Principles and Practices examination
with a 75 percent average.
FLEX/USMLE scores: The Federation’s Examination and Board Action and History
Report (EBAHR) must be sent from:
The Federation of State Medical Boards, P.O. Box 619850, Dallas, TX 75261-9850
Phone 817-868-4000.
Online: http://www.fsmb.org.transcripts.html
• Other state examinations may be accepted if they include an Osteopathic
Principles and Practices section. The Board will determine if the other state’s
examination is equal to the Washington State examination requirements.
Examination scores must be certied by the state where the examination was
taken.
State Examination
The USMLE (Step 1, 2, and 3) is the approved state examination after December 1993.
Steps 1 and 2 are taken during osteopathic medical school. In addition to the USMLE
exam, applicants must obtain a 75 percent average on the Washington Osteopathic
Principles and Practices examination to complete the examination requirements.
DOH 663-035 November 2021 Page 2 of 4
USMLE, STEP 3 Eligibility
• Graduate of an accredited osteopathic medical school. Graduation must be
conrmed by the Federation of State Medical Board (FSMB) Step 3 deadline
date.
• The examination application, instructions, and deadline dates may be obtained
on the Federation of State Medical Board (FSMB) website.
Application for Limited License While in Postgraduate
Training
A limited license is issued to practice osteopathic medicine and surgery while you are
training in a postgraduate (internship, residency, or fellowship) program in Washington.
The limited license does not authorize you to engage in practice outside the training
program. The limited license permits practice only under supervision of a physician
licensed in Washington State under Chapter 18.57 RCW or Chapter 18.71 RCW.
Requirements:
F Completed application form - Check Limited License (Postgraduate Program).
Limited license application fee. You can check the fee page for current fees.
F Ocial osteopathic school transcripts indicating osteopathic doctorate degree.
F Completion of the Limited License Postgraduate Training Verication form by the
program director from your training program in Washington State.
F Verication of state licenses as described in the documents required to be
submitted section, if applicable.
Limited licenses are issued for one year from the beginning date of your postgraduate
training and may be renewed annually until completion of the program.
Alternative Documents Accepted – Federation Credentials
Verication Service (FCVS)
The Federation of State Medical Boards has a central repository for core physician
documents. Core documents are dened as the basic documents that do not change,
for example, transcripts, postgraduate training, and examination scores. The FCVS
is operated on behalf of participating state medical boards but your participation is
optional. At your request, those core documents will be provided to the designated state
licensing board.
The Board will accept the core documents from FCVS. In addition to the core
documents, you may need to submit other documents to complete the application le.
You will still be required to provide state verications and any other information specied
in the instructions that apply to your application. The Board may make further inquiries
or conduct an investigation related to information provided during the application
process.
For information on participating in the FCVS or ordering core documents, contact
1-888-ASK-FCVS (275-3287), Online: http://www.fsmb.org/fcvs.html, or email
DOH 663-035 November 2021 Page 3 of 4
Other Background Information Checked by the Board for all
Applicants
• AOA prole
• Federation of State Medical Board Data Bank Report
• National Practitioner Data Bank Report
• Washington State Criminal Background Report
The current address and telephone number of a healthcare provider governed under
RCW 18.130 is not public information.
Additional Information:
• The application process is considered condential. Information about a pending
application will only be provided to the applicant, or a person identied in writing
by the applicant.
• Applications and supporting documents should be complete at least 60 days
before you anticipate beginning work in Washington State. After initial review,
more documentation or information may be requested. More time may also be
required to complete any investigation requested by the Board. Practice is not
permitted prior to issuance of a license.
• Verication forms have been included in the packet for your convenience. You
are not required to use these specic forms, but verications must contain all of
the information specied on the forms.
• All documents must be received from the originating source. Documents
verifying your education, training, or state licenses will not be accepted from
you. Copies or faxed documents will not be accepted.
DOH 663-035 November 2021 Page 4 of 4
DOH 663-001 April 2024 Page 1 of 5
Revenue 0252070000
Date
Stamp
Here
Name: First Middle Last
Note: The mailing and email addresses you provide will be your addresses of record. It is your responsibility to
maintain current contact information on le with the department.
Country
Will documents be received in another name? F Yes F No
If yes, list name(s):
Address
City State Zip Code County
Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #)
Email address
Have you ever been known under any other name(s)? F Yes F No
If yes, list name(s):
Country
Mailing address if dierent from above address of record
City State Zip Code County
Birth date (mm/dd/yyyy)
1. Demographic Information
Osteopathic Medicine and Surgery License Application
Application for (check one):
F Full License
F Limited License
F Temporary Permit
Application for license is made by (check one):
F National Board Endorsement
F FLEX Endorsement/Washington Examination
F USMLE Endorsement/Washington Examination
F State Examination Endorsement
Social Security Number (SSN)
(If you do not have a SSN, see instructions)
F Male F Female
F Prefer Not to Answer
F X
National Provider Identier Number (NPI)
(Enter 10 digit number)
Select if the following applies: F Spouse or Registered Domestic Partner of Military Personnel
DOH 663-001 April 2024 Page 2 of 5
Please Note:
The Board does not inquire about personal medical conditions unless notied that they represent a
limitation or impairment to safe medical practice.
“Medical Condition” includes social, behavioral, physical, physiological, and psychological conditions or
disorders. The Board of Osteopathic Medicine and Surgery (BOMS) does inquire about substance use of
applicants. If you have a medical condition or substance use disorder that may limit or impair your ability
to practice medicine safely, it is your responsibility to contact the Washington Physician Health Program
(WPHP) for an assessment: 800-552-7236. If the behavior or condition is “Known to WPHP”, that means you
have informed WPHP of your medical condition(s) and you are complying with all WPHP requirements for
evaluation, treatment, and/or monitoring - if any. The BOMS considers this a safe haven in the application
process.
Acknowledgement and Agreement
By submitting this application, you acknowledge and agree to the following:
If the Board has information that you may be suering from a condition for which you are not being
appropriately treated that impairs your judgement or would adversely aect your ability to practice medicine
in a competent, ethical, and professional manner, the Board may request that you undergo an evaluation
with the WPHP or obtain other health examinations at your expense. By submitting this application, you
consent to such examination(s). You also agree the full and complete examination report(s) may be provided
to the Board, which is the regulatory authority of the license. You waive all claims based on condentiality or
privileged communication. You understand that failure to submit to a required examination(s) or provide the
requested report(s) to the Board may be grounds for denying your application.
1. Do you have a medical condition which in any way impairs or limits your ability to practice your
profession with reasonable skill and safety? If yes, please attach explanation. .......................................F F
“Medical Condition” includes physiological, mental or psychological conditions or
disorders, such as, but not limited to orthopedic, visual, speech, and hearing impairments,
cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes,
intellectual disabilities, emotional or mental illness, specic learning disabilities, HIV disease,
tuberculosis, drug addiction, and alcoholism.
If you answered yes to question 1, explain:
1a. How your treatment has reduced or eliminated the limitations caused by your medical condition.
1b. How your eld of practice, the setting or manner of practice has reduced or eliminated the
limitations caused by your medical condition.
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.
2. Personal Data Questions
Yes No
3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or
frotteurism? ............................................................................................................................................... F F
4. Are you currently engaged in the illegal use of controlled substances? ...................................................F F
“Currently” means within the past two years.
Illegal use of controlled substances is the use of controlled substances (e.g., heroin, cocaine)
not obtained legally or taken according to the directions of a licensed health care practitioner.
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.
5. 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 5, 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.
If you have been granted certicate(s) of restoration of opportunity, please
provide a certied copy of each certicate.
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.
6. 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
7. 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
8. 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
9. Have you ever surrendered a credential like those listed in number 8, in connection with or to
avoid action by a state, federal, or foreign authority? ...............................................................................F F
10. 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
11. Have you ever had hospital privileges, medical society, other professional society or organization
membership revoked, suspended, restricted or denied? .......................................................................... F F
12. Have you ever been the subject of any informal or formal disciplinary action related to the practice
of medicine?. ............................................................................................................................................F F
13. 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
14. Have you ever agreed to restrict, surrender, or resign your practice in lieu of or to avoid adverse
action?. .....................................................................................................................................................F F
15. Have you ever been disqualied from working with vulnerable persons by the Department
of Social and Health Services (DSHS)? ...................................................................................................F F
DOH 663-001 April 2024 Page 3 of 5
2. Personal Data Questions (Cont.)
Yes No
4. Experience
In date order, most recent to later, list all professional experience since completion of post-graduate training. Exclude
activities listed under other sections. Attach additional completed pages if you need more space.
Name of practice or experience and location
From
(mm/yyyy)
To
(mm/yyyy)
Type of experience or specialty
DOH 663-001 April 2024 Page 4 of 5
3. Osteopathic Medical Education and Post Graduate Training
Provide in date order, most recent to later, your osteopathic educational preparation and post-graduate training.
Attach additional completed pages if you need more space.
Schools Attended
Osteopathic medical education (list all osteopathic schools attended and location)
Post graduate training
Years
attended
Dates Granted
Start
(dd/mm/yyyy)
End
(dd/mm/yyyy)
Medical Speciality
5. Other License, Certication, or Registration
List all credentials to practice osteopathic medicine in any states or US Territories.
State or territory
Certicate
Permanent or
Temporary
License Received
Currently in force
Year Number Exam Other
F Yes F No
F Yes F No
F Yes F No
F Yes F No
DOH 663-001 April 2024 Page 5 of 5
6. 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 have read all laws and rules related to my profession.
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 __________________________________ By: _______________________________________
(Original signature of applicant)
(Print applicant name clearly)
(mm/dd/yyyy)
(This page intentionally left blank.)
This is to certify that___________________________________ has been accepted in
a postgraduate training program in________________________________________ at
__________________________________________________ for the period beginning
________________________. The individual responsible for this resident’s patient care
activities will be________________________________________________________.
Program address________________________________________________________
Signature ______________________________________________________________
* A resident osteopathic physician means an individual who has graduated from an
approved school of osteopathic medicine. The resident must be serving a period
of postgraduate clinical training sponsored by a college or university in this state or
by a hospital accredited in this state whose program is approved by the American
Osteopathic Association, the American Medical Association or by their recognized
aliate residency accrediting organizations. The term shall include individuals
designated as intern, resident, or medical fellow.
Return completed form to the address listed above.
Training Appointment Verication
Name of osteopathic* physician
DOH 663-036 November 2021
Type of residency program
WA State training institution
Start date
Director of program (print name)
Osteopathic Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700
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State License Investigative Letter
DOH 663-038 November 2021
To assist the Washington State Board in evaluating the above osteopathic physician’s application, we
would appreciate receiving the following information.
License Number: Date license was issued:
Status of License: F Active F Military F Other F Inactive F Expired
Has the applicant’s license ever been suspended or revoked? F Yes F No
Has any other disciplinary or corrective active been taken? F Yes F No
Has the licensee surrendered the license in lieu of disciplinary action? F Yes F No
If you have answered yes to any of the questions above, attach supporting documentation pertaining to
disciplinary orders or any other actions.
State Seal
Name of applicant (please print): Birth date (mm/dd/yyyy):
I have applied for a license to practice osteopathic medicine and surgery in the state of Washington. Before
my request for a license can be reviewed, a background investigation must be completed. Please complete
the following questionnaire relative to my state license and return it the address listed above.
Please reply as soon as possible to avoid delays in the licensing process.
I hereby authorize you to release the following information to the Washington State Osteopathic Medical
Board.
Signature of Applicant: Date (mm/dd/yyyy):
State Board:
Address:
Phone (enter 10 digit #):
Authorized Signature: Date:
Osteopathic Credentialing
PO Box 47877
Olympia, WA 98504-7877
360-236-4700
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RCW/WAC Links
Uniform Disciplinary Act, RCW 18.130
Administrative Procedure Act, RCW 34.05
Administrative Procedures and Requirements, WAC 246-12
Osteopathic Medicine and Surgery Laws, RCW 18.57
Osteopathic Medicine and Surgery Rules, WAC 246-853
Continuing Education
Osteopathic Continuing Medical Education Rules, WAC 246-853-060
Online
Board of Osteopathic Medicine and Surgery, Web page
RCW/WAC and Online Website Links
DOH RCW/WAC November 2021
