Follow the steps to successfully complete the WA HCA 18-0011 form online.

1. Press the ‘Get Form’ button to access the WA HCA 18-0011 form. This action will allow you to open the document in the online editor, where you can begin your entries.
2. In Section 1, provide the Medical Records Company (MRC) information. Enter the legal name of your company along with the Federal Tax ID, Doing Business As (DBA) name, and the UBI/Business License number.
3. In Section 2, fill out the MRC’s Primary Business Location information. Indicate the primary business name, complete the street address, city, state, zip code + 4, telephone number, email, and fax number.
4. Move to Section 3, where you will enter the MRC’s Mailing and Pay-to Address. Again, provide the street address, city, state, and zip code + 4.
5. In Section 4, tackle the MRC Debarment, Suspension, and Exclusion Checklist. Answer the questions regarding any fines or convictions. If applicable, provide details of adverse legal action in the specified format.
6. Proceed to Section 5 to acknowledge the Payment Agreement for the MRC. Review the stipulations regarding record provision, legal compliance, HIPAA compliance, use of personal information, billing, governing law, and other terms. Ensure you understand these before moving on.
7. Complete the certification section at the end of the form. Here, you will need to sign and date the document to declare that the information is accurate and that you have the authority to act on behalf of the MRC.
8. Once you have filled out the entire form, you can save your changes, download a copy, or print the form for your records. Make sure to share or submit the document according to the instructions provided.

Get started on completing your WA HCA 18-0011 form online today!