Electronic Prescribing Waiver Attestation Form

You will be asked to complete the following set of questions to submit a waiver request.

Provider First and Last Name

License Type (Your Profession)

License number

Today's Date: mm/dd/yyyy

You will then be asked to select one reason for submittal of the waiver. Please choose only one of the potential options that best explain the reason for your submittal.

Please print screen the final page before selecting the “Finish” button. 

You will need to submit a waiver by December 1st of each year (by December 1, 2022 for calendar year 2023 and so forth), for the next upcoming year.

Information collected via this form may be subject to release in accordance with chapter 42.56 RCW (Public Records Act).

Please contact your programs Program Manager or Executive Director if you have any questions or need assistance.