Deadline/Where to Return Paperwork
At least 2 weeks prior to your clinical rotation. Send paperwork directly to the site.
Paperwork to Complete
1. Evergeen HIPPA for Covered Entities
2. HIPPA Assessment
3. Nurse Practitioner Application - Ky Pham in Academic Servies will sign off on the immunization attestation form for you to put in with the rest of your application. Please contact Ky Pham at firstname.lastname@example.org for this portion of your application.
At least 2 weeks prior to your rotation, mail these to:
Lynnette Wahl, Administrative Coordinator - Education Department
425.899.2524 (p) | 425.899.2459 (f) | email@example.com
EvergreenHealth MS-106, 12040 NE 128th St., Kirkland, WA 98034
Contact the Site
Midwifery students Only:
Diane Kovar, CPMSM
Manager, Medical Staff Office
Phone: (425) 899-1891
Diane will help you schedule an appointment to arrange completion of the remainder of your paperwork. Bring the following with you:
- Driver's license or passport
- Social Security Card
For ARNP/CNS students:
Karla Bushmaker, RN, MN
Staff Development Specialist
Phone: (425) 899-2529
Additional Site Requirements
- The seasonal influenza vaccination is required for all students coming to Evergreen for clinical experiences.