Aging and Long-Term Support Administration

Sign Language Interpreter Renewal Form

Please fill out the DSHS Background Application first. https://fortress.wa.gov/dshs/bcs/. You will need the Confirmation Number to complete this renewal form.

Personal Information
Applying for registry with:
First Name:  
Middle Initial:
Last Name:  
Date of Birth:
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Street Address:
City:  
State:
Zip Code:
County of Residence
First Telephone Number (Including Area Code):
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Second Telephone Number (Including Area Code):
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Email Address:     Home Work Mobile
Email Address:   Home Work Mobile


Background Check

All Sign Language Interpreters are required to fill out DSHS background check authorization application online. https://fortress.wa.gov/dshs/bcs

Once you fill out the on-line application, you will receive a confirmation code via email. Please add that code below.
 
Confirmation Code:

Confidential Agreement per DSHS Form 03-374b

“Confidential Information” means information that is exempt from disclosure to the public or other unauthorized persons under Chapter 42.56 RCW or other federal or state laws. Confidential Information includes, but is not limited to, protected health information as defined by the federal rules adopted to implement the Health Insurance Portability and Accountability Act of 1996, 42 USC §1320d (HIPAA), and Personal Information.

“Personal Information” means information identifiable to any person, including, but not limited to, information that relates to a person’s name, health, finances, education, business, use or receipt of governmental services or other activities, addresses, telephone numbers, social security numbers, driver license numbers, other identifying numbers, and any financial identifiers or as otherwise identified in RCW 42.56.230.

State laws (including RCW 74.04.060 and RCW 70.02.020) and federal regulations (including HIPAA Privacy and Security Rules; 42 CFR, Part 2; 42 CFR Part 431) prohibit unauthorized access, use, or disclosure of Confidential Information. Violation of these laws may result in criminal or civil penalties or fines. You may face civil penalties for violating HIPAA Privacy and Security Rules up to $50,000 per violation and up to $1,500,000 per calendar year as well as criminal penalties up to $250,000 and ten years imprisonment.

Assurance of Confidentiality

In consideration for the Department of Social and Health Services (DSHS) and any other agency granting me access to state property, systems, and Confidential Information, I agree that I: (must check all)

Will not use, publish, transfer, sell or otherwise disclose any Confidential Information gained by reason of this agreement for any purpose that is not directly connected with the performance of the contracted services except as allowed by law.
Will protect and maintain all Confidential Information gained by reason this agreement against unauthorized use, access, disclosure, modification or loss.
Will employ reasonable security measures, including restricting access to Confidential Information by physically securing any computers, documents, or other media containing Confidential Information.
Have an authorized business requirement to access and use DSHS systems or property, and view its data and Confidential Information if necessary.
Will access, use and/or disclose only the “minimum necessary” Confidential Information required to perform my assigned job duties.
Will not share DSHS system passwords with anyone or allow others to use the DSHS systems logged in as me.
Will not distribute, transfer, or otherwise share any DSHS software with anyone.
Understand the penalties and sanctions associated with unauthorized access or disclosure of Confidential Information.
Will forward all requests that I may receive to disclose Confidential Information to my supervisor for resolution.
Understand that my assurance of confidentiality and these requirements do not cease at the time I terminate my relationship with my employer or DSHS.

Declaration

I have read and understand the current NAD-RID Code of Professional Conduct and agree to abide by it.
I have read and understand the BEI Code of Professional Conduct and agree to abide by it.
I understand that some of my information will be posted on the DSHS website and/or in the Directory of Services.
I am a Qualified Deaf Interpreter, I have read and understand the DSHS Code of Professional Conduct and agree to abide by it.

I understand that if any of information provided above is found to be false, it may preclude me from providing services under the DSHS and/or HCA contract.  This document is signed and sworn under penalty of perjury.  I certify that the above information is true and correct.

My signature on this registration form authorizes DSHS/ODHH to review and/or obtain conviction records from the Washington State Patrol and other states; and to obtain from Washington and other states licensing information and any determination or finding of abuse, neglect or exploitation. 

I understand that the results of this background check* will be kept in total confidence and may be released or reviewed by DSHS when monitoring contract compliance.  Any convictions or findings resulting after ODHH registration and approval shall be reported to ODHH within two working days.

Signed on Date: 
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Registration Submittal