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RN SUCCESSPAYS PRE-APPROVALANCC CERTIFICATION REQUESTThis application is to apply for pre-certification reimbursement through the SuccessPays program, which applies only for ANCC certifications. Mercyhealth RN Partners that are required to hold a specific certification to maintain their position, or would enhance their current position with Mercyhealth are eligible for payment of the cost of their certification as stated in the HR-100-CERTIFICATION policy. Once this request has been approved, the partner will receive a confirmation notification with an access code to complete certification in the SuccessPays portal. The partner has 90-days from date of confirmation notification to complete the certification and return a copy of successful completion of certification. If a partner does not successfully complete certification the first time, they can make a second attempt at no cost. If the certification is more than the amount allowed the partner will be required to reimburse Mercyhealth the additional cost through payroll deduction. For approval:Complete the information requested belowAttach copy of desired ANCC certification brochure or website indicating content and costsSubmit to Department Director/Manager for approvalForward to the Human Resource department for processingNameEmployee NumberEmail Address (confirmation notification will be sent to this email address)Contact NumberDepartment/LocationPosition/Job TitleType of ANCC Certification. Is this a new certification or a renewal?Cost of CertificationDate of EmploymentStatus (FTE or hours work weekly)Have you previously received reimbursement for a specialty certification? If so, what certification?By signing this request partner agrees to the following:Partner has 90-days from date of confirmation notification to complete the Success Pays certification.The access code received is a one-time code for your use only and is not to be shared with any other partner.Review the HR-100 certification policy for additional requirements, tax liability and maximum eligibility amount.Partner Signature DateDepartment Director/Manager Approval Date Human Resources Only:Approved byDate confirmation notification sentCompletion dateAccess codeAmount of certification$Successful completionY or NPayroll notificationAs payroll deduction or taxable incomeAccount number11-998220-71008Other:Revised 04-15-2021 ................
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