Forms & Reports

Disclosure of or Change in Ownership and Control of Interest Form

Completion and submission of the Disclosure of or Change in Ownership and Control of Interest Form is a condition of participation and full and accurate disclosure of ownership and financial interest is required.

Download form here:


Standardized Delegated Report Template

The WCSG Shared Audit Team has created a new reporting tool that is compliant with Health Plan, NCQA, CMS, HEDIS, and State Medicaid requirements for credentialing. The Standardized Delegate Report Template is a reporting tool that is used by medical groups delegated for credentialing functions and accepted by Aetna, Amerigroup, Centene Corporation, Cigna Health Care, Community Health Plan, First Choice Health Network, Kaiser Permanente Washington, Humana, Molina Healthcare of WA, Northwest Physician Network, ODS HealthPlan Inc, OptumHealth, PacMed Clinics, Premera/Blue Cross LifeWise Health Plans, Regence Blue Shield, Soundpath Health and United Healthcare/Pacificare health plans.

The reporting tool was created by a work group consisting of medical groups, health plans, and vendors with a focus on crafting one tool that all medical groups could use to report practitioner information to the health plans. This one template, accepted by all health plans above, can alleviate some of the extra work for medical groups who maintain reports for each health plan they have delegation with. It also assists the health plans with loading the data into their systems to better ensure accurate claims payment and online directories.

The tool may be downloaded here:  2022_Standardized_Delegated_Roster_Template FINAL

Any questions about the tool should be directed to the Standardized Delegate Roster Lead, Amy Condon.


Recreational Use of Marijuana/Cannabis by Physicians Members of Hospital Medical Staff

From the Director of Legal Affairs, Washington State Medical Association

Thank you for your inquiry. The WSMA does not have a policy specifically on the issue of physicians’ use of recreational marijuana. I have copied the existing WSMA policies on marijuana in general:

  • The WSMA supports completion of ongoing studies legislated by RCW 69.51, regarding the clinical efficacy of marijuana. (Res C-6, A-96; EC Rpt L, A-97; Res C-9, A-98)
  • The WSMA supports reclassification of marijuana’s status as a Schedule I controlled substance to a more appropriate schedule. (Res A-2, A-08)
  • The WSMA supports efforts to cease the criminal prosecution and other enforcement actions against physicians and patients acting in accordance with state medical marijuana law. (Res A-2, A-08)

That being said, the WSMA has a long-standing concerning impairment of physicians regardless of the cause. Please take a look at the information the WSMA has posted on our website regarding both medical and recreational marijuana. WSMA Medical and Recreational Marijuana. (pdf format)

In particular, you might find interesting the article by Dr. Charles Meredith, director of the Washington Physicians Health Program. While his article speaks about medical marijuana, he raises concerns about physicians’ use of marijuana, even for medical purposes.

I hope this information is helpful. Please contact me if you have questions or desire additional information.

Best regards,

Denny Maher, JD, MD
Director of Legal Affairs
Washington State Medical Association
2001 Sixth Avenue, Suite 2700
Seattle, Washington 98121