WA DOH 670-114 2023-2025 free printable template
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Agency Affiliated Counselor Credentialing P. O. Box 47877 Olympia WA 98504-7877 360-236-4700 Check One c New Agency c Update / Change Agency c Additional Agency Applicants may not provide unsupervised counseling prior to completion of a criminal background check performed by either the employer or the Department of Health. Agency or Facility Employer Name City State Zip Code My Agency is a county state agency federally recognized Indian tribe located within Washington State or has been...
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How to fill out WA DOH 670-114
01
Download the WA DOH 670-114 form from the Washington State Department of Health website.
02
Read the instructions carefully before starting to fill out the form.
03
Provide your personal information in the designated fields, including your name, address, and contact information.
04
Fill in the relevant health information as requested, ensuring accuracy and completeness.
05
If applicable, provide information regarding any immunizations or medical history.
06
Review the completed form for any errors or omissions.
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Sign and date the form where indicated.
08
Submit the form as instructed, either by mail or electronically.
Who needs WA DOH 670-114?
01
Individuals applying for a specific health-related service or program in Washington State.
02
Parents or guardians submitting health information for minors.
03
Healthcare providers needing to document health information for their patients.
04
Anyone required to report health information for compliance purposes.
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What is WA DOH 670-114?
WA DOH 670-114 is a form used for reporting certain health-related data to the Washington State Department of Health.
Who is required to file WA DOH 670-114?
Healthcare providers, facilities, or organizations that are mandated to report specific health information under state law are required to file WA DOH 670-114.
How to fill out WA DOH 670-114?
To fill out WA DOH 670-114, users must provide accurate and complete information as requested on the form, including patient details, treatment information, and any relevant dates.
What is the purpose of WA DOH 670-114?
The purpose of WA DOH 670-114 is to collect data that supports public health initiatives, monitoring, and assessments in Washington State.
What information must be reported on WA DOH 670-114?
The information that must be reported on WA DOH 670-114 includes patient demographics, clinical outcomes, treatment types, and other relevant health information as specified by the form's instructions.
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