WISCONSIN NURSES ASSOCIATION



133350-24574500 APPROVED PROVIDER INTENT TO APPLY/ ELIGIBILITY VERIFICATIONThank you for your interest in applying for Approved Provider status through the Midwest Multistate Division. Organizations interested in applying for provider approval must complete the eligibility verification process, meet all eligibility requirements and submit a $200 intent-to-apply fee. The Midwest Multistate Division will review the documentation and determine if the applicant is eligible to apply. This document must be completed and submitted electronically (as a Word document) to the Midwest MSD office at least six months prior to the application submission deadline [see Approved Provider Application Instructions for application submission deadlines]. Submit completed forms to ApprovedProviders@.The $200.00 intent-to-apply fee may be paid by check or credit card through the Midwest MSD website. The intent-to-apply fee is non-refundable if the organization submits an intent-to-apply form and decides not to proceed with the submission of the full Approved Provider application package. The intent-to-apply fee will be credited toward the provider application review fee for organizations that proceed forward with the full Provider Application package submission.This form should be completed by an individual with the authority and knowledge to attest to the eligibility of this organization to apply for Approved Provider status. Midwest MSD staff will notify you within one month of receipt if your organization is eligible to apply for Approved Provider status. Contact the Midwest MSD Office at ApprovedProviders@ or 573-636-4623, ext. 102 with questions. The Midwest Multistate Division is accredited as an approver of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.DEMOGRAPHICS Name of Applicant Organization: Mailing Address:(Address, City, State, ZIP)Contact Person:Title/Position:Email Address:Daytime Phone:Organization Type:? College or University ? Healthcare Facility ? Specialty Nursing Organization ? Health-Related Organization ? Multidisciplinary Educational Group? Professional Nursing Education GroupType of Applicant:Renewal ApplicantFirst time ApplicantType of Provider:Single Agency ProviderSystem Provider (Questions? Please see Application Instructions)New applicant – Year you intend to apply to the Midwest MSD for Approved Provider status:Which review cycle? FebruaryJuneOctoberExample: February Review cycle (application deadline February 1; approval decision finalized by June 1)Current Provider – Provider Approval Number:Approved by:Approval expiration date:Which review cycle? FebruaryJuneOctoberExample: February Review cycle (application deadline February 1; approval decision finalized by June 1)ELIGIBILITY VERIFICATIONTo be eligible to apply for Approved Provider status, an organization must meet the following criteria: 1.The organization must have a clearly defined ‘Provider Unit’, a department administratively and operationally responsible for nursing continuing professional development. An Approved Provider Unit (APU) is defined structurally and operationally as the members of the organization who support the delivery of Nursing Continuing Professional Development (NCPD) activities.A. My provider unit is: A free-standing organization whose sole purpose is to offer nursing professional development programs for nurses (single-focused organization) e.g. a continuing education companyPart of an organization that does more than just offer nursing professional development programs for nurses (multi- focused organization) e.g. a hospital, college or universityB. If your organization is multi-focused, is there a separate, clearly defined ‘provider unit’ administratively and operationally responsible for planning, implementing, and evaluating nursing continuing professional development?YESNO – Please stop and contact the Midwest MSD Office to discuss eligibility2.The organization must have at least one Nurse Planner (NP) who will serve as the Primary Nurse Planner (PNP) and be responsible for adhering to ANCC/Midwest MSD accreditation criteria in the provision of nursing continuing professional development. A. Identify the PNP responsible for adhering to ANCC/Midwest MSD accreditation criteria in the provision of NCPD:Name and Credentials:Daytime Phone:Email Address:B. Please list the names and credentials of all current Nurse Planners:Nurse Planner NameCredentialsC. All Nurse Planners are currently licensed Registered Nurses with baccalaureate degrees or higher in nursing.YESNO – Please stop and contact the Midwest MSD Office to discuss eligibilityD. A designated Nurse Planner from the list above is an active participant in the planning, implementing and evaluation process of each continuing education activity, from beginning to end.YESNO – Please stop and contact the Midwest MSD Office to discuss eligibility3.The organization must limit their marketing, promotion or advertisement of nursing continuing professional development (NCPD) to nurses in either their local DHHS region or a state contiguous to that single region (click here for HHS region map). In percentages, this means that less than 50% of the organization’s programs are marketed to nurses within the states of their region or a state contiguous to their region. If the organization markets/promotes/advertises 50% or more of their programs to nurses outside of their region or a state contiguous to that region, they are not eligible to apply for Approved Provider status through the Midwest MSD and must apply directly to the American Nurses Credentialing Center (ANCC) to become an Accredited Provider.During the past year, our organization marketed/promoted/advertised 50% or more of its NCPD programs to nurses within our local DHHS region or a state contiguous to this region.YESNO – Please stop and contact the Midwest MSD Office to discuss eligibility4.The organization must be one or more of the following, check all that apply:Hospital, long-term care facility, nursing home, or rehabilitation center; for-profit or nonprofitNonprofit organization or professional associationCollege or UniversityConstituent Member Association or Specialty Nursing OrganizationNational nurses organization based outside the United StatesGovernment organizationBlood bankDiagnostic laboratoryFederal Nursing ServiceGroup medical practiceHealth insurance providerLiability insurance providerNon-health care related companyProvider of healthcare information technologySingle-focused organization devoted only to providing nursing continuing professional developmentIf the organization is NOT one of the types listed above:Does the applicant organization produce, market, re-sell, or distribute health care goods or services consumed by, or used on, patients? YES – Please stop and contact the Midwest MSD Office to discuss eligibilityNO – Proceed to question 4BIs the applicant organization owned or controlled by a multi-focused organization (MFO) that produces, markets, re-sells, or distributes health care goods or services consumed by, or used on, patients? YES – Proceed to question 4CNO – You have completed this question and should proceed to Question 5Is the applicant organization a separate and distinct entity from the MFO?YES – Proceed to question 5 (additional questions may apply)NO – The organization is NOT a separate and distinct entity from the MFO please stop and contact the Midwest MSD Office to discuss eligibility5.The organization must comply with all applicable federal, state, and local laws and regulations that apply to the delivery of nursing continuing professional development (NCPD). Our organization is in compliance with all applicable federal, state, and local laws and regulations that apply to the delivery of nursing continuing professional development (NCPD). YESNO – Please stop and contact the Midwest MSD Office to discuss eligibility.-381007429500RENEWAL APPLICANTS:A. Our organization has been in operation (functioning under current Midwest MSD/ANCC accreditation criteria with all essential Provider Unit personnel in place) for a minimum of six months prior to applying for Approved Provider status.YES – proceed to Question BNO – Please stop and contact the Midwest MSD Office to discuss eligibility.B. Our organization has experienced a change in Primary Nurse Planner in the past six months.YES – Please stop and contact the Midwest MSD Office to discuss eligibilityNO – proceed to Question CC. Our organization assessed, planned, implemented, and evaluated at least three separate educational activities (of the minimum of 5 required per year), within the past 12 months, provided at separate and distinct events, that:Xdirectly involved a designated Nurse PlannerXadhered to ANCC/Midwest MSD accreditation criteria; and,Xwere at least one contact hour in lengthYES – proceed to Statement of UnderstandingNO – Please stop and contact the Midwest MSD Office to discuss eligibility.D. Proceed to Statement of UnderstandingFIRST TIME APPLICANTS:A. Our organization has been operational (functioning under current Midwest MSD/ANCC Accreditation criteria with all essential Provider Unit personnel in place) for a minimum of six months prior to applying for Approved Provider status.YES – proceed to Question BNO – Please stop and contact the Midwest MSD Office to discuss eligibility.B. Our organization assessed, planned, implemented, and evaluated at least three separate educational activities (of the minimum of 5 required per year), within the past 12 months, provided at separate and distinct events, that:Xdirectly involved a designated Nurse Planner from the list aboveXadhered to ANCC/Midwest MSD accreditation criteriaXwere approved by the Midwest MSD Approver Unit or another ANCC Accredited Approver within the past 12 monthsXwere at least one contact hour in length; and,Xwere not jointly provided.YES – proceed to Question CNO – Please stop and contact the Midwest MSD Office to discuss eligibility.C. Provide the names and offering date(s) of the three activities that were individually approved and that will be submitted with the upcoming provider application below:Activity Title:Date Provided:Activity Title:Date Provided:Activity Title:Date Provided:D. Proceed to Statement of UnderstandingSTATEMENT OF UNDERSTANDINGI attest, by my signature below, that I am duly authorized by [Insert name of organization] to apply to the Midwest MSD for Approved Provider status under the American Nurses Credentialing Center (ANCC) accreditation criteria and to make the statements herein. On behalf of my organization, I have read the Approved Provider eligibility requirements and criteria. I understand that my organization is subject to all eligibility requirements and criteria as an Approved Provider. I understand that becoming an Approved Provider depends on successfully meeting eligibility requirements and criteria and maintaining Approved Provider standing is dependent upon continued compliance. On behalf of my organization, I expressly acknowledge and agree that information accumulated through the approval process may be used for statistical, research, and evaluation purposes and that anonymous and aggregate data may be released to third parties. Otherwise, all information will be kept confidential and shall not be used for any other purposes without my organization’s permission.On behalf of my organization, I hereby certify that the information provided on this document is true, complete, and correct. I further attest that this organization will comply with all eligibility requirements and approval criteria throughout the entire approval period, including all reapplication periods for maintaining approval, and that our organization will notify the Midwest MSD Office promptly if, for any reason while this application is pending or during any approval period, our organization does not maintain compliance. I understand that any misstatement of material fact submitted on, with or in furtherance of this application for Approved Provider status shall be sufficient cause for Midwest MSD to deny, suspend or terminate our organization’s Approved Provider status and to take other appropriate action against the organization. Electronic Signature: Name and credentials provided in the box below serves as the electronic signature of the Primary Nurse Planner. Name and Credentials: Date:OFFICE USE ONLYDate Eligibility Form Received: Eligible to Apply for Approved Provider Status: ? YES ? NODecision Made by:Date:Comments:Assigned to which review cycle? ? FEBRUARY ? JUNE ? OCTOBER Year:Date Organization Notified: ................
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