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 - you do not need to get your immunizations. Academic Services will coordinate the immunization attestation form for you to put with the rest 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) | firstname.lastname@example.org
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.
The School of Nursing Will Provide to the Site:
- School Attestation Form- In order for Academic Services to fill out your form, we will need your consent to release of records form. Please fill out this form and email Anh Shafer your completed form at email@example.com.