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MERCYHEALTHRN 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 applicable policy of your organization. Legacy Mercy partners follow HR-01-CERTIFICATION and Legacy Rockford partners follow E1.03 TUITION REIMBURSEMENT. 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. This second attempt must occur within the original 90-day timeframe. 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.Reference the appropriate policy (Legacy Mercy HR-01 Certification/Legacy Rockford E1.03 Tuition Reimbursement) 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 06.24.16MERCYHEALTHRN SUCCESS PAYS CONFIRMATIONDate:TO:FROM:Congratulations! Your request for an RN Success Pays certification has been approved. Mercyhealth wishes you success as you pursue your professional development goals.Please remember these important items:The certification you will be completing is __________________________.The access code is. This code is only to be used with this approval and is not to be shared with anyone else.You have 90-days from the date of the SuccessPays confirmation notification to successfully complete your certification and return proof of your certification directly to me by___________.Upon successful completion, the cost of this certification will be considered a taxable benefit and added to your earnings. The amount would be: $_______________________.You have two tries within the 90 day period per the ANCC to complete your certification. Instructions for accessing the Success Pays portal are:Log into the ANCC website ()Click?on the appropriate specialty certificationAfter the page for your specialty has successfully loaded, click “Apply Online”.If you do not already have an account, click “Register” located under “New Customer” and complete the customer registration.? If you already have an account, complete the required fields to login to your account.Select/Add Certification? to cartOn the checkout page, enter the discount code as 33728748 in the “Enter Promotional Code” field.Click “Apply Promo” to adjust the order total to $0.00.Click “Process My Order” towards the bottom left of the page as the final step of the certification registration process.Please let us know if you have any difficulties with submitting your application and we will contact the ANCC. If you have any questions, please contact me at __________________________. ................
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