Washington Practitioner Application

To use the Washington Practitioner Application (WPA), follow these instructions:

Keep an unsigned and undated copy of the application on file for future requests. When a request
is received, send a copy of the completed application, making sure that all information is complete, current
and accurate.
Please sign and date pages 11 and 13 .
Please document any YES responses on the Attestation Question page.
Identify the health care related organization(s) to which this application is being submitted in the space
provided below.
Attach copies of requested documents each time the application is submitted.
If changes must be made to the completed application, strike out the information and write in the
modification, initial and date.
If a section does not apply to you, please check the provided box at the top of the section.
Expect addendums from the requesting organizations for information not included on the WPA.

This application is submitted to:

1. INSTRUCTIONS
This form should be typed or legibly printed in black or blue ink. If more space is needed than provided on original, attach
additional sheets and reference the question being answered. Please do not use abbreviations. Current copies of the
following documents must be submitted with this application: (all are required for MDs, DOs; as applicable for other
health practitioners).
DEA Certificate Curriculum Vitae (Not an acceptable substitute for
Face Sheet of Professional Liability Policy or Certificate completing the application. Dates need to be listed in
mm/yyyy Format)
** All sections must be completed in their entirety. **

2. PRACTITIONER INFORMATION – Legal Name Required

Last Name: (include suffix; Jr., Sr., III) First: Middle: Degree(s):
Denslow Maya Marie BS,DMD
List any other name(s) under which you have been known by reference, licensing and or educational institutions:

Home Mailing Address: City:

Tacoma
4005 N 18th Street
State: Zip Code:
WA 98406
Home Telephone Number: Pager Number: Cell Phone Number: E-Mail Address:
( ) ( ) ( 616) 502 8390 mayadenslow@ gmail.com
Birth Date: (mm/dd/yyyy) Birth Place (city, state, country): Citizenship:
05/28/1996 Grand Rapids,MI,United States Citizen
Social Security Number: Male Female Languages Fluently Spoken by Practitioner:
384-19-6536 English
Have you ever voluntarily opted-out of Medicare? Yes No

NPI: Medicare Number: (WA) Medicaid (DSHS) Number(s): L & I Number(s):

1578282067
Specialty primarily practicing: Sub specialties primarily practicing:
General Dentist
Other Professional Interests in Practice, Research, etc.:

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 3. PRACTICE INFORMATION CHECK ALL THAT APPLY
Effective Date at PRIMARY Practice location (MM/YY) __________
Practice Setting
Clinic/Group Solo Practice Home Based Hospital Based Primary Care Site Urgent Care Other
Practitioner Profile
PCP Specialist Check if you are both PCP & OB OB in your practice Yes No Deliveries Yes No
Name of Practice / Affiliation or Clinic Name: Department Name (if hospital based):

Primary Office Street Address: City:

State: Zip Code: Org. NPI#:

Patient Appointment Telephone Number: Fax Number:

( ) ( )
Mailing Address: (if different from above)

Billing Address: (if different from above)

Practice Website
Office Manager / Administrator Name: Administration Telephone Number:
( )
E-mail Address: Fax Number:
( )
Credentialing Contact (if different from above): Telephone Number:
( )
E-mail Address: Fax Number:
( )
Name Affiliated with Tax ID Number: Federal Tax ID Number:

Is the office wheelchair accessible? Yes No

Office Hours
Are you accepting new patients? Yes No Monday: ________________________
Have you limited your practice in any way (e.g. 18 years or older?) Tuesday: ________________________
Yes No If yes, please explain: Wednesday: ______________________
_________________________________________________________ Thursday: ________________________
_________________________________________________________ Friday: __________________________
Do you currently supervise ARNP’s or PA’s? Yes No Saturday: ________________________
If yes, please provide the name and specialty below: Sunday:__________________________
_________________________________________________________ Do you provide 24 hour coverage? Yes No
_________________________________________________________ If no, please explain how your patients obtain
Please list languages fluently spoken by office staff: advice and care after hours:
_________________________________________________________ _________________________________________
_________________________________________________________ _________________________________________

A. Hospital Inpatient Coverage Plan (for those without admitting privileges) Does Not Apply
Name of Admitting Physician/Practice/Clinic/Group: Hospital Where privileged:

B. Office Covering Practitioners/Call Group Does Not Apply

Provider Name, Degree Specialty Address Phone Number

Attach a list of additional covering practitioners if needed

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 Effective Date at SECONDARY Practice location (MM/YYYY) CHECK ALL THAT APPLY
Practice Setting
Clinic/Group Solo Practice Home Based Hospital Based Primary Care Site Urgent Care Other
Practitioner Profile
PCP Specialist Check if you are both PCP & OB OB in your practice Yes No Deliveries Yes No
Name of Secondary Practice / Affiliation or Clinic Name: Department Name (if hospital based):

Primary Office Street Address: City:

State: Zip Code: Org. NPI#

Patient Appointment Telephone Number: Fax Number:

( ) ( )
Mailing Address: (if different from above)

Billing Address: (if different from above)

Practice Website
Office Manager / Administrator Name: Administration Telephone Number:
( )
E-mail Address: Fax Number:
( )
Credentialing Contact (if different from above): Telephone Number:
( )
E-mail Address: Fax Number:
( )
Name Affiliated with Tax ID Number: Federal Tax ID Number:

Is the office wheelchair accessible? Yes No Office Hours

Are you accepting new patients? Yes No Monday: ________________________

Have you limited your practice in any way (e.g. 18 years or older?) Tuesday: ________________________
Yes No If yes, please explain: Wednesday: ______________________
_________________________________________________________ Thursday: ________________________
_________________________________________________________ Friday: __________________________
Do you currently supervise ARNP’s or PA’s? Yes No Saturday: ________________________
If yes, please provide the name and specialty below: Sunday:__________________________
_________________________________________________________ Do you provide 24 hour coverage? Yes No
_________________________________________________________ If no, please explain how your patients obtain
Please list languages fluently spoken by office staff: advice and care after hours:
_________________________________________________________ _________________________________________
_________________________________________________________ _________________________________________
_________________________________________
A. Hospital Inpatient Coverage Plan (for those without admitting privileges) Does Not Apply
Name of Admitting Physician/Practice/Clinic/Group: Hospital Where privileged:

B. Office Covering Practitioners/Call Group Does Not Apply

Provider Name, Degree Specialty Address Phone Number

Attach a list of additional covering practitioners if needed

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 LIST OTHER OFFICE LOCATIONS WITH THE ABOVE INFORMATION ON A SEPARATE SHEET

4. PROFESSIONAL LICENSURE, REGISTRATIONS AND CERTIFICATIONS

(Attach Additional Sheet if Necessary)
Washington State Professional License/Registration/Cert Issue Date: Expiration Date:
Number: DE61327761 07/25/2022 05/28/2024
Name of Sponsor if required by licensure, (e.g. Physician’s Assistant).

Pharmacists Collaborative Drug Therapy Agreement (CDTA) Number(s):

Drug Enforcement Administration (DEA) Registration Number: Expiration Date:

FD2253944 06/30/2025
ECFMG Number (applicable to foreign medical graduates): Date Issued:
07/25/2022
5. ALL OTHER PROFESSIONAL LICENSES, REGISTRATIONS AND CERTIFICATIONS
State: Lic/Reg/Cert Number: Date Issued Exp. Date Yr. Relinquish Reason:
MI 2901601519 08/25/22 08/25/25
State: Lic/Reg/Cert Number: Date Issued Exp. Date Yr. Relinquish Reason:

State: Lic/Reg/Cert Number: Date Issued Exp. Date Yr. Relinquish Reason:

6. UNDERGRADUATE EDUCATION (Do not abbreviate) Does Not Apply

School/College/University/Vocational Education: Degree Received(be specific, e.g. BS Graduation Date
Biology) (mm/yyyy)
Michigan State University BS Neuroscience 05/2018
Mailing Address: City: State: Zip Code:
426 Auditorium Road East Lansing MI 48824
College or University Name: Degree Received(be specific, e.g. BS Graduation Date
Biology) (mm/yyyy)

Mailing Address: City: State: Zip Code:

7. MASTER DEGREE PROGRAM OR POST GRADUATE EDUCATION Does Not Apply

Institution: Address City State Zip Code:

Dates Attended (mm/yyyy - mm/yyyy): Program or Course of Study:

( / )-( / )
Faculty Director: Degree:

8. MEDICAL/PROFESSIONAL EDUCATION (Do not abbreviate)

Medical/Professional School: Start Date: Graduation Date Degree Received
(mm/yyyy) (mm/yyyy)
Oregon Health & Science UniversitySchool ofDentistry 07/2018 06/2022 DMD
Mailing Address: City: State: Zip Code:
2730 S MoodyAve Portland OR 97201
Medical/Professional School: Start Date Graduation Date Degree Received
(mm/yyyy) (mm/yyyy)

Mailing Address: City: State: Zip Code:

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 9. INTERNSHIP/PGYI (Attach Additional Sheet if Necessary) Does Not Apply
Institution: Phone Number: Fax Number: Program Director:

Mailing Address: City: State: Zip Code:

Type of Internship: Specialty: From (mm/yyyy): To (mm/yyyy):

10. RESIDENCIES (Attach Additional Sheet if Necessary) Does Not Apply

Institution: Phone Number: Fax Number: Program Director:

Mailing Address: City: State: Zip Code:

Type of Residency: Specialty: From (mm/yyyy): To (mm/yyyy):

Did you successfully complete the program? Yes No (If "No", please explain on separate sheet.)
Institution: Phone Number: Fax Number: Program Director:

Mailing Address: City: State: Zip Code:

Type of Residency: Specialty: From (mm/yyyy): To (mm/yyyy):

Did you successfully complete the program? Yes No (If "No", please explain on separate sheet.)
11. FELLOWSHIPS (Attach Additional Sheet if Necessary) Does Not Apply
Institution: Phone Number: Fax Number: Program Director:

Mailing Address: City: State: Zip Code:

Course of Study: From (mm/yyyy): To (mm/yyyy):

Did you successfully complete the program? Yes No (If "No", please explain on separate sheet.)
Institution: Phone Number: Fax Number: Program Director:

Mailing Address: City: State: Zip Code:

Course of Study: From (mm/yyyy): To (mm/yyyy):

Did you successfully complete the program? Yes No (If "No", please explain on separate sheet.)
12. PRECEPTORSHIP (Attach Additional Sheet if Necessary) Does Not Apply
Institution: Address: City: State: Zip Code:

Telephone Number Fax Number Email Address

( ) ( )
Dates Attended (mm/yyyy - mm/yyyy): Training: Department Chairman:
( / )-( / )

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 13. FACULTY/TEACHING APPOINTMENTS (Attach Additional Sheet if Necessary) Does Not Apply
Institution: Address: City: State: Zip Code:

Telephone Number Fax Number Email Address

( ) ( )
Dates Attended (mm/yyyy - mm/yyyy): Position: Faculty Director:
( / )-( / )
14. BOARD CERTIFICATION Does Not Apply
Are you board or otherwise professionally certified?
Yes If "Yes", please complete No If "No", describe your intent for certification, if any, and dates of testing for
below: Certification on separate sheet.
Date Recertified Expiration Date
Issuing Board/Entity and State Issued Specialty Date Certified (if any)

Have you applied for certification other than those indicated above? Yes No
If so, list certification and date:

Certification number if applicable:

If you participate in a specialty which does not have board certification, please indicate specialty:

15. OTHER CERTIFICATIONS ACLS, BLS, ATLS, PALS, NALS (e.g., Fluoroscopy, Radiography, etc.)
(Attach Certificate if Applicable)
Type: BLS Number: Expiration Date: 03/
2024
225413434854
Type: Number: Expiration Date:

16. HOSPITAL, MILITARY, & OTHER INSTITUTIONAL AFFILIATIONS Does Not Apply
Please list in reverse chronological order (with the current affiliation(s) first) all institutions where you (A) Current Hospital
affiliation, (B) Previous Hospital Affiliations, (C) Current Military Affiliation, (D) Previous Military Affiliations (E) Applications in
process This includes hospitals, surgery centers, institutions, corporations, military assignments, or government agencies. If
more space is needed, attach additional sheet(s). List only affiliations here, list employment in section XVII, Work History.
A. CURRENT HOSPITAL AFFILIATIONS (Do not abbreviate)
Name of Primary Admitting Hospital: Department:

Mailing Address City, State , Zip

Phone number: Fax Number:
Status (active, provisional, courtesy, temporary, etc.): Appointment Date (mm/yyyy):

Can you admit / follow clients of your primary, secondary, other practice locations? Does Not Apply
Primary practice admits only Secondary Practice admits only can admit to for all locations
Name of Secondary Admitting Hospital: Department:

Mailing Address City, State, Zip

Phone number: Fax Number:

Status: Appointment Date (mm/yyyy):

Can you admit / follow clients of your primary, secondary, other practice locations? Does Not Apply
Primary practice admits only Secondary Practice admits only Can admit to for all locations
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 Name of Other Institutions: Department:

Mailing Address City, State, Zip

Phone number: Fax Number:

Status: Appointment Date (mm/yyyy):

Can you admit / follow clients of your primary, secondary, other practice locations? Does Not Apply
Primary practice admits only Secondary Practice admits only Can admit to for all locations
B. PREVIOUS HOSPITAL AFFILIATIONS (Do not abbreviate)
Name of Admitting Hospital: Department:

Mailing Address City, State, Zip

Previous Status (active, provisional, courtesy, temporary, etc.): From (mm/yyyy): To (mm/yyyy):

Reason for Leaving:

Name of Admitting Hospital: Department:

Mailing Address City, State, Zip

Previous Status (active, provisional, courtesy, temporary, etc.): From (mm/yyyy): To (mm/yyyy):

Reason for Leaving:

Name of Admitting Hospital: Department:

Mailing Address City, State, Zip

Previous Status (active, provisional, courtesy, temporary, etc.): From (mm/yyyy): To (mm/yyyy):

Reason for Leaving:

C. CURRENT MILITARY AFFILIATIONS (Do not abbreviate) Please include Military Reserves
Name of Primary Base: Division

Mailing Address City, State , Zip

Phone number: Fax Number:

Status (active, provisional, courtesy, temporary, etc.): Appointment Date (mm/yyyy):

D. PREVIOUS MILITARY AFFILIATIONS (Do not abbreviate)

Name of Primary Base: Division

Mailing Address City, State , Zip

Phone number: Fax Number:

Status (active, provisional, courtesy, temporary, etc.): Appointment Date (mm/yyyy):

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 E. APPLICATIONS IN PROCESS (Do not abbreviate)
Hospital/Institution: Phone Number/Fax Number: Date Application Submitted:

Mailing Address: City: State: Zip Code:

Hospital/Institution: Phone Number/Fax Number: Date Application Submitted(mm/yyyy)

Mailing Address: City: State: Zip Code:

17. WORK HISTORY (Do not abbreviate)

Chronologically list all work history activities since completion of professional training (use extra sheets if necessary). This
information must be complete. Curriculum vitae is not sufficient.
Name of Practice / Employer: Contact Name: Telephone Number:
InfinityDental -Highpoint Flats Lisa Papes ( ) 930-
231- 3130
Reason for Leaving: Email Address Fax Number:
moved to W A ( )

Mailing Address City: State: Zip: From (mm/yyyy) To (mm/yyyy)

285 W W estern Ave #102 Muskegon MI 49440 07/2022 06/2023
Name of Practice / Employer: Contact Name: Telephone Number:
O'
Connor Dentistry Beth O'
Connor ( 253-) 584-2124
Reason for Leaving: Email Address Fax Number:
( )
Not busyenough
Mailing Address: City: State: Zip Code: From (mm/yyyy): To (mm/yyyy):
9618 59th Ave SW Lakewood WA 98499 07/23 12/23
Name of Practice / Employer: Contact Name: Telephone Number:
Northwest Dental Medicine ( ) 845-
253- 9507
Reason for Leaving: Email Address Fax Number:
Not busyenough ( )

Mailing Address: City: State: Zip Code: From (mm/yyyy): To (mm/yyyy):

2903 E Main Ave Puyallup WA 98372 08/23 12/23
18. GAPS IN HISTORY. Please account for all gaps between dates of medical/professional school graduation to
present not covered elsewhere within this application. Include dates, activity and names where applicable:

From (mm/yyyy): To (mm/yyyy):

19. PEER REFERENCES

List at least three professional references, from your specialty area, not including relatives, who have worked with you in the
past two years. References must be from individuals who, through recent observation, are directly familiar with your work and
can attest to your clinical competence in your specialty area. If you have been out of residency or fellowship for a period of
less than three years, one reference must be from the Program Director. Allied Health Providers must provide at least one
reference from their same discipline.
Name of Reference: Title and Specialty: E-mail Address:
Connor Drangsholt Associate Dentist connordrangsholt@ gmail.com
Mailing Address: City: State: Zip Code:
9618 59th Ave SW Lakewood WA 98499
Telephone Number: Fax Number: Cell Phone Number: (Optional)
( ) 253-584-2124 ( ) ( )

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 Name of Reference: Title and Specialty: E-mail Address:
Beth O'
Connor Owner Dentist drbethoc@ gmail.com
Mailing Address: City: State: Zip Code:
9618 59th Ave SW Lakewood WA 98499
Telephone Number: Fax Number: Cell Phone Number: (Optional)
( ) 253-584-2124 ( ) ( )
Name of Reference: Title and Specialty: E-mail Address:
Ross Drangsholt
Mailing Address: City: State: Zip Code:
9618 59th Ave SW Lakewood WA 98499
Telephone Number: Fax Number: Cell Phone Number: (Optional)
( ) 253-512-0265 ( ) ( )
20. PROFESSIONAL AFFILIATIONS (Do not abbreviate)
Please List Membership In All Professional Societies
Complete Name of Society: Date Joined Current Member

/ / . YES NO

/ / . YES NO
21. PROFESSIONAL LIABILITY (Do not abbreviate)
A. Current Insurance Carrier: Policy Number:
Aspen American Insurance Company
Mailing Address: City: State: Zip Code:
12611 Des Moines Mem.Dr.PO Box68787 Seattle WA 98168
Phone Number: Fax Number:
206-248-2254 206-248-0130
Per claim amount: $ Aggregate amount: $ Date Began (mm/yyyy): Expiration Date
$1,000,000 $3,000,000 06/17/2023 06/17/2024
(mm/yyyy):
B. PREVIOUS PROFESSIONAL LIABILITY CARRIERS WITHIN THE LAST TEN YEARS (Do not abbreviate)
(Attach Additional Sheet if Necessary)
Name of Carrier: Policy Number:
The Cincinnati Insurance Company ECP 0528466
Mailing Address: City: State: Zip Code:
1700 E Beltline Ave NE Suite 120 Grand Rapids MI 49525
Phone Number: Fax Number:
616-719-4311 616-719-4311
Per claim amount: $ Aggregate amount: $ Date Began (mm/yyyy): 03/14/20
Expiration Date
$1,000,000 $1,000,000 03/14/2023 (mm/yyyy): 24
Name of Carrier: Policy Number:

Mailing Address: City: State: Zip Code:

Phone Number: Fax Number:

Per claim amount: $ Aggregate amount: $ Date Began (mm/yyyy): Expiration Date
(mm/yyyy):
Name of Carrier: Policy Number:

Mailing Address: City: State: Zip Code:

Phone Number: Fax Number:

Per claim amount: $ Aggregate amount: $ Date Began (mm/yyyy): Expiration Date
(mm/yyyy):
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 Name of Carrier: Policy Number:

Mailing Address: City: State: Zip Code:

Phone Number: Fax Number:

Per claim amount: $ Aggregate amount: $ Date Began (mm/yyyy): Expiration Date
(mm/yyyy):
Name of Carrier: Policy Number:

Mailing Address: City: State: Zip Code:

Phone Number: Fax Number:

Per claim amount: $ Aggregate amount: $ Date Began (mm/yyyy): Expiration Date
(mm/yyyy):
Name of Carrier: Policy Number:

Mailing Address: City: State: Zip Code:

Phone Number: Fax Number:

Per claim amount: $ Aggregate amount: $ Date Began (mm/yyyy): Expiration Date
(mm/yyyy):
Name of Carrier: Policy Number:

Mailing Address: City: State: Zip Code:

Phone Number: Fax Number:

Per claim amount: $ Aggregate amount: $ Date Began (mm/yyyy): Expiration Date
(mm/yyyy):

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WASHINGTON PRACTITIONER ATTESTATION QUESTIONS - To be completed by the practitioner
Please answer all of the following questions. If your answer to any of the following questions is 'Yes", provide details as specified
on a separate sheet. If you attach additional sheets, sign and date each sheet.
A. PROFESSIONAL SANCTIONS
1. Have you ever been, or are you now in the process of being denied, revoked, terminated, suspended, restricted, reduced,
limited, sanctioned, placed on probation, monitored, or not renewed for any of the following? Or have you voluntarily or
involuntarily relinquished, withdrawn, or failed to proceed with an application for any of the following in order to avoid an
adverse action or to preclude an investigation or while under investigation relating to professional competence or conduct?
a. License to practice any profession in any jurisdiction YES NO
b. Other professional registration or certification in any jurisdiction YES NO
c. Specialty or subspecialty board certification YES NO
d. Membership on any hospital medical staff YES NO
e. Clinical privileges at any facility, including hospitals, ambulatory surgical centers, skilled nursing YES NO
facilities, etc.
f. Medicare, Medicaid, FDA, NIH (Office of Human Research Protection), governmental, national YES NO
or international regulatory agency or any public program
g. Professional society membership or fellowship YES NO
h. Participation/membership in an HMO, PPO, IPA, PHO, Health Plan or other entity YES NO
i. Academic Appointment YES NO
j. Authority to prescribe controlled substances (DEA or other authority) YES NO
2. Have you ever been subject to review, challenges, and/or disciplinary action, formal or informal, by YES NO
an ethics committee, licensing board, medical disciplinary board, professional association or
education/training institution?
3. Have you been found by a state professional disciplinary board to have committed unprofessional YES NO
conduct as defined in applicable state provisions?
4. Have you ever been the subject of any reports to a state, federal, national data bank, or state YES NO
licensing or disciplinary entity?
B. CRIMINAL HISTORY
1. Have you ever been charged with a criminal violation (felony or misdemeanor) resulting in either a YES NO
plea bargain, conviction on the original or lesser charge, or payment of a fine, suspended sentence,
community service or other obligation?
a. Do you have notice of any such anticipated charges? YES NO
b. Are you currently under governmental investigation? YES NO
C. AFFIRMATION OF ABILITIES
1. Do you presently use any drugs illegally? YES NO
2. Do you have, or have you had in the last five years, any physical condition, mental health condition, YES NO
or chemical dependency condition (alcohol or other substance) that affects or will affect your current
ability to practice with or without reasonable accommodation? If reasonable accommodation is
required, specify the accommodations required. If the answer to this question is yes, please identify
and describe any rehabilitation program in which you are or were enrolled which assures your ability
to adhere to prevailing standards of professional performance.
3. Are you unable to perform any of the services/clinical privileges required by the applicable YES NO
participating practitioner agreement/hospital agreement, with or without reasonable accommodation,
according to accepted standards of professional performance?
D. LITIGATION AND MALPRACTICE COVERAGE HISTORY (If you answer "Yes" to any of the questions in this
section, please document in Section XXI. PROFESSIONAL LIABILITY ACTION DETAIL of this application.)
1. Have allegations or claims of professional negligence been made against you at any time, whether or YES NO
not you were individually named in the claim or lawsuit?
2. Have you or your insurance carrier(s) ever paid any money on your behalf to settle/resolve a YES NO
professional malpractice claim (not necessarily a lawsuit) and/or to satisfy a judgement (court-
ordered damage award) in a professional lawsuit?
3. Are there any such claims being asserted against you now? YES NO
4. Have you ever been denied professional liability coverage or has your coverage ever been YES NO
terminated, not renewed, restricted, or modified (e.g. reduced limits, restricted coverage,
surcharged)?
5. Are any of the privileges that you are requesting not covered by your current malpractice coverage? YES NO
I warrant that all the statements made on this form and on any attached information sheets are complete, accurate, and current. I
understand that any material misstatements in, or omissions from, this statement constitute cause for denial of membership or cause
for summary dismissal from the entity to which this statement has been submitted.

Applicant's Signature: Date

Type or Print name here Maya Denslow

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 22. PROFESSIONAL LIABILITY ACTION DETAIL – CONFIDENTIAL Does Not Apply
Practitioner Name:(print or type)

Please list any past or current professional liability claim(s) or lawsuit(s), in which allegations of professional
negligence were made against you, whether or not you were individually named in the claim or lawsuit. Please do
not include patient names or other HIPAA protected PHI. Photocopy this page as needed and submit a separate
page for EACH claim/event. A legible signed practitioner narrative that addresses all of the following details is an
acceptable alternative.
Date and clinical details of the incident, with preceding events:
Date: Details:

Your role and specific responsibility in the incident:

Subsequent events, including patient’s clinical outcome:

Date suit or claim was filed:

Name and Address of Insurance Carrier that handled the claim:

Your status in the legal action (primary defendant, co-defendant, other):

Current status of suit or other action:

Date of settlement, judgment, or dismissal:

If case was settled out-of-court, or with a judgment, settlement amount attributed to you? $

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23. ATTESTATION
I certify the information in this entire application is complete, accurate, and current. I acknowledge that any misstatements in or
omissions from this application constitute cause for denial of membership or cause for summary dismissal from the entity to
which this statement has been made. A photocopy of this application has the same force and effect as the original. I have
reviewed this information as of the most recent date listed below.

Print Name
Here: Maya Denslow

Signature:
(Stamped signature is not acceptable)

Date:

Review dates and initials:

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Healthcare Organization: -
And/or Designated Agent:
WASHINGTON PRACTITIONER APPLICATION AUTHORIZATION AND RELEASE OF INFORMATION FORM
Modified Releases Will Not Be Accepted
By submitting this authorization and release of information form in conjunction with the Washington Practitioner Application (WPA) and/or the
Washington Practitioner Attestation or Credentials Update (CU) form, I understand and agree as follows:
1. I understand and acknowledge that, as an applicant for medical staff membership and/or participating status with the Healthcare
Organization(s)* indicated on the WPA for initial credentialing or recredentialing, I have the burden of producing adequate information for
proper evaluation of my competence, character, ethics, mental and physical health status, and or other qualifications in a timely manner. I
understand that the application will not be processed until the application is deemed complete by the healthcare organization.
2. I further understand and acknowledge that the Healthcare Organization(s) or designated agent will investigate the information in this
application. By submitting this application, I agree to such investigation and to information exchange activities of the Healthcare
Organization(s) as part of the verification and credentialing process.
3. I authorize all individuals, institutions and entities or organizations with which I am currently or have been associated and all professional
liability insurers with which I have had or currently have professional liability insurance, who may have information bearing on my
professional qualifications, ethical standing, competence, and mental and physical health status to release the aforementioned information
to the designated Healthcare Organization(s), their staffs and agents.
4. I consent to the inspection of records and documents that may be material to an evaluation of qualifications and my ability to carry out the
clinical privileges or provide services I request. I authorize each and every individual and organization in custody of such records and
documents to permit such inspection and copying. I am willing to make myself available for interviews if required or requested.
5. I release from any liability, to the fullest extent permitted by law, all persons for their acts performed in a reasonable manner in conjunction
with providing information, investigating and evaluating my application and qualifications, and I waive all legal claims against any
representative of the Healthcare Organization(s) or their respective agent(s) who act in good faith and without malice in connection with
the investigation of this application.
6. I acknowledge that I have been informed of, and hereby agree to abide by, the bylaws, rules, regulations, contractual agreements, and
policies of the Healthcare Organization.
7 I acknowledge that I am responsible for notifying the Healthcare Organization of any changes/challenges to licensure, DEA, malpractice
claims, criminal convictions, hospital privileges or other disciplinary actions.
8. I attest to the accuracy, currency and completeness of the information provided. I understand and agree that any misstatements in or
omissions from the CU, WPA, Washington Practitioner Attestation and attachments hereto may constitute cause for denial of the
application or summary dismissal or termination of membership/clinical privileges/participation agreement.

9. I agree to exhaust all available procedures and remedies as outlined in the bylaws, rules, regulations, and policies, and/or contractual
agreements of the Healthcare Organization(s) where I have membership and/or clinical privileges/participation status before initiating
judicial action.

10. I understand that completion and submission of the Authorization and Release does not automatically grant me membership or clinical
privileges/participating status with the Healthcare Organization(s)* indicated on the WPA/CU or Attestation.

11. I hereby further authorize and consent to the release of information and/or reporting by the Healthcare Organization(s) to medical
associations, licensing boards, the National Practitioner Data Bank, the Healthcare Integrity and Protection Data Bank, and other similar
organizations regarding any pertinent information which the Healthcare Organization(s) may have concerning me as long as such release
of information and/or reporting is done in good faith and without malice, and I hereby release from liability Healthcare Organization(s) and
its staff and representatives for so doing.

12. I further acknowledge that I have read and understand the foregoing Authorization and Release. A photocopy of this Authorization and
Release shall be as effective as the original and authorization constitutes my written authorization and request to communicate any
relevant information and to release any and all supportive documentation regarding this application/attestation.
Print Name
Here: Maya Denslow

Signature:

(Stamped signature is not acceptable)

Date:
*Healthcare Organization (e.g. hospital, medical staff, medical group, independent practice association, professional review organization health plan,
health maintenance organization, preferred provider organization, physician hospital organization, medical society, credentials verification
organization, professional association, medical school faculty position or other health delivery entity or system).

Washington Practitioner Application January 201 Page 14 of 14 PRACTITIONER NAME:

Modification to the wording or format of the Washington Practitioner Application may invalidate the application.