WebThe DOH, Health Systems Quality Assurance response to the novel Coronavirus (COVID-19) outbreak may delay our ability to process paper licensure applications submitted through the USPS. We encourage health care providers wishing to obtain a new license in Washington state to submit their application through our online services A B C D E F G H … WebForm CMS 10065-IM (Exp. 12/31/2024) OMB approval 0938-1019 {Insert contact information here} Important Message from Medicare . Patient name: Patient number:
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