Medical Commission Contact Information Change Form

• For assistance filling out this form, please contact the Medical Commission Credentialing Unit at 360-236-2750.
• For faster service, press ‘Email’ to electronically submit this form to the Medical Commission.
• The completed form can be printed and mailed or faxed to:
  Washington State Medical Commission
  Credentialing Unit
  P.O. Box 47866
  Olympia WA 98504-7866
  
  Fax: 360-236-2795
  Medical.Commission@doh.wa.gov

DOH 658-023 July 2013