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.
Street 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?
If you have an HM CC Credential Number, enter it below. Enter only Numbers
Example: HMCC.HM.1234567
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

HCA Exam Fee

Required payment to secure your exam seat.

$150.00

HCA Skills Exam Retake Fee

Skills retake fee

$90.00

Enter coupon

Subtotal

Tax

Total

Credit Card

Apple Pay

Google Pay

Cash App Pay

Please go to our website and review instructions on how to apply for the HCA license on the DSHS website.

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