Massage Therapist Expired Credential Reactivation
Packet
Contents:
1. 676-102 .....Contents List/SSN Information/Mailing Information ....................... 1 page
2. 676-103 .....Application Instructions Checklist ................................................ 2 pages
3. 676-104 .....Massage Therapist Expired Credential
Reactivation Application ............................................................... 3 pages
4. 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 ap-
plication 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 lo-
cate 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 Send other documents not sent
documentation and your check with initial application to:
or money order payable to:
Department of Health Board of Massage 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 hear-
ing customers, please call 711 (Washington Relay) or email [email protected].
DOH 676-102 September 2021
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DOH 676-103 September 2021 Page 1 of 2
Application Instructions Checklist
You will be notied in writing if further documentation is required.
To ensure you have submitted the necessary fees and documentation, we encourage
you to use the following checklist:
F Pay Late Penalty Fee.
F Pay Current Renewal Fee.
F Pay Expired Credential Reissuance Fee.
All fees are non-refundable. You can check the online fee page for current fees.
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 on your
credential. Be sure to include the city, state, zip code, county, and country. This will
be your permanent address with 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.
F 2. Other License, Certication, or Registration. List all states, including
Washington, where credentials are or were held. Attach additional completed pages
if you need more space. You must also print the Verication Form and provide it to
each state or jurisdiction that you have listed, requesting that they complete and
submit the form directly to the Department of Health.
F 3. Professional Experience. In date order, list all your professional work
experience since your Washington State credential expired. Attach additional
pages if you need more space.
F 4. Disciplinary Action Attestation. Required by WAC 246-12-040.
F 5. Continuing Education Attestation. Required by WAC 246-12-040.
F 6. Applicant’s Attestation. Required to be both signed and dated in order to
process the application.
DOH 676-103 September 2021 Page 2 of 2
DOH 676-104 September 2021 Page 1 of 3
Revenue 0242010000
Date
Stamp
Here
Name First Middle Last
Massage Practitioner Expired
Credential Activation Application
1. Demographic Information
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
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)
Phone (enter 10 digit #) Fax (enter 10 digit #) Cell (enter 10 digit #)
Email address
Please print clearly. It is the responsibility of the applicant to submit or request all required supporting
documents be submitted. Failure to do so may result in a delay in processing your application.
F Male F Female
F Prefer not to answer
F X
Social Security Number (SSN)
(If you do not have a SSN, see instructions)
National Provider Identier Number (NPI)
(Enter 10 digit number)
DOH 676-104 September 2021 Page 2 of 3
List in date order, most recent to later all your credentials you have held since last being credentialed in
Washington State. Include your last active licensed in Washington State.
2. Other License, Certication, or Registration
3. Professional Experience
List in date order, most recent to later, all your professional work experience since your Washington State credential
expired.
Type of experience of practice and location
Credential
State/Jurisdiction Profession
Type Number Yr Issued Credentialing
Method of
No
Yes
Currently in force
Start (mm/yyyy) End (mm/yyyy)
DOH 676-104 September 2021 Page 3 of 3
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 ____________________________ at ______________________________________________
By: _______________________________________
(Signature of applicant)
(Print applicant name clearly)
(mm/dd/yyyy)
APPLICANT’S INITIALS
4. Disciplinary Action Attestation
I certify that I have met all continuing education and competency requirements for the past two
years. I am enclosing documentation on all classes attended/claimed.
I certify that no action has been taken by any state or federal jurisdiction or hospital, which would prevent or restrict
my right to practice my profession.
I further certify that I have not voluntarily given up any credential or privilege or have not been
restricted in the practice of my profession in lieu of or to avoid formal action.
APPLICANT’S INITIALS
5. Continuing Education/Continuing Competency Attestation (If Applicable)
(City, state)
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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
Online
Board of Massage Web Page
National Certication Board, www.ncbtmb.com
Federation of State Massage Therapy Boards, www.fsmtb.org
Washington State Approved Massage Programs School List
Jurisprudence Examination
RCW/WAC and Online Website Links
RCW/WAC and Online Website Links September 2021
