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DOH 651-006 – Completed Guidance for NCMA Credential Verification
This document provides the exact language and selections to be used by the National Certification Medical Association (NCMA) when completing the Washington State Out-of-State Credential Verification Form (DOH 651-006).
Section: Authority Providing Verification
Authority Providing Verification:
National Certification Medical Association (NCMA)
National Credentialing Authority for Allied Health Professionals
Title: Chair, Advisory Board / Credentialing Authority
Credentialing Method
Applicant was credentialed by:
☑ Written Examination
Name of Examination:
National Clinical Medical Assistant Certification Examination (NCMA)
☑ Other Examination (if applicable)
Clinical competency assessment / skills validation
Score:
Pass / Fail – Minimum national competency standard met
Credential Status
Is credential current? ☑ Yes
Expiration Date: ____________________
Is individual in good standing? ☑ Yes
Disciplinary History
Has this credential ever been denied? ☐ No
Suspended? ☐ No
Revoked? ☐ No
Surrendered? ☐ No
Reinstated? ☐ No
If credential holder has been disciplined:
☑ All requirements successfully completed and individual is in good standing
Signature:
______________________________
Name: ________________________
Title: Chair, Advisory Board / Credentialing Authority
National Certification Medical Association (NCMA)
Date: ________________________