HCA Exam Student Intake Form

HCA Exam Student Intake Form

Provide your details, credentials, and signature to secure your exam appointment and proceed with payment.
Student Information
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Credential Details
Have you completed an application through the Washington State Department of Health (DOH) online portal? Do you have a pending HM CC Credential Number?*

Yes, I have completed the application and have a credential number.No, I have not completed the application.
If you have an HM CC Credential Number, enter it below.*
Student Signature
75 Hour Certificate School Details
Name of Training Program Name: *
Found on the 75 hours of DSHS Approved Certificate
Name of Training Instructor*
Date of Completion of the 75 Hrs Training*

MonthDayYear
Date
75-Hour HCA Certificate Upload
Please upload your 75-hour HCA Certificate below.*

Hint!! Take a screenshot of the certificate, save it to photos then upload it!!
Cancelof
Payment Authorization

My Products*

HCA Exam Fee

Required payment to secure your exam seat.

$150.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card

Apple Pay

Google Pay