CERTIFICATION & CONTINUING EDUCATION APPLICATION
National Certification Services, LC- www.Med-Certification.com
Medical Billing-Coding, Office Administration, Medical Assistant, Scribe, certify here.
First name ________________ MI____ Last name __________
Address: _______________________City ________________
State__________ ZIP_________ Email __________________
Phone: ________________ Cell _________________________
Highest education level completed:
_____ High school ____ Associate ____ Bachelor ____ Master ___ Doctorate
___ MD ___DO ___RN ___Other ___
Where do You Work?
Business Name ____________Address: City ___________________ State_____ZIP________
Phone ___________ Title: ____________
Length of employment___
Gender: ___ M ___ F Date of Birth ____________________ (xx/xx/xxxx)
Which of the following best describes the classification of your organization?
____Medical practice (solo, single-specialty, multi-specialty, etc.)
____Academic practice (clinical science department, faculty practice plan, etc.)
____Service organization (accounting, consulting, etc.)
____Other health care delivery organization
Education. High school graduate ___ or GED ____. Other training and/or experience (6 months on the job or proof of training program completion) _____________________________________________
Options – Check your selection
1. _____Practice Test (no records are kept, no annual fees are required)
2. _____Certification records will be maintained for one year. Thereafter, an annual fee $55 is required to maintain an active certification.
3. _____Certification and CEU registration. To establish and maintain both certification and CEU records, the fee is $99 one year after certification is acquired. You will be required to provide CEUs as applicable to your specialty.
4. _____CEUs only. If you certify elsewhere but want to obtain and have your CEUs tracked here at Med-Certification, the fee is $50. If you obtain CEUs for the first time, the fee is $50 and your annual fee is included. Thereafter, you will pay $50 for the annual fee and $50 for every 12 hours of CEUs.
Note: No fees except the testing fees are due for one year after certifying.
Certification Testing/Continuing Education Credits
CBS Medical Billing Specialist – Practice Test ____ ($99) Cert test ____ ($239)
CCA Coding Associate – Practice Test ____($99) Cert test ____($349)
CBCS Billing-Coding Specialist – Practice Test ____($99) Cert test ____($349)
CMA Medical Assistant – Practice Test ____ ($99) Cert test ____ ($229)
CMAA Medical Administration – Practice Test ___ ($99) Cert test ____ ($369)
CHIS Health Insurance – Practice Test ____ ($99) Cert test ____ ($199)
MTC Medical Transcriptionist – Practice Test ____ ($99) Cert test ____ ($349)
MTCX Medical Transcriptionist – Practice Test ____ ($99) Cert test ____ ($369)
ICD10 Certification Practice Test ____($59) Cert Test ____($139)
MA-C Medication Aide-Certified Cert Test $389 full test prep and test, $299 test only
CLT Legal Transcriptionist Practice Test ____ ($79) Cert test ____ ($299)
CPL Paralegal/Legal Assistant Practice Test ____ ($69) Cert test ____ ($369)
____CEUs $50 per 12 units/hours
SIGNATURE ______________________________ DATE: _________
PRINTED NAME AS IT WILL APPEAR ON YOUR CERTIFICATE (Certification and CEUs)
EMAIL, SCAN AND EMAIL SNAILMAIL OR FAX YOUR APPLICATION TO: (Call or email for fax number)
National Certification Services, PO Box 1201, Layton, UT 84041-1201; EMAIL email@example.com
NOTE: All dollar amounts are listed in U.S. currency. To activate membership, payment must be made in full. Application and membership fees are not refundable. Yearly membership is renewable on member’s anniversary date.