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THE AMERICAN HOLISTIC NURSES CREDENTIALING CORPORATIONAPPLICATION FOR INACTIVE STATUSFOR AHNCC CERTIFIED REGISTERED NURSES(Holistic Nurses and Nurse Coaches)Revised April 28, 2019IntroductionCertified holistic nurses who are temporarily unable to meet the requirements for recertification and need an extension of time to fulfill recertification requirements may convert their status to “Inactive” status. Converting to inactive status allows certified nurses up to three years from their original scheduled renewal date to meet eligibility requirements. Certification may be reactivated at any time during the three-year period. Certification will be reactivated upon completion of the recertification requirements and payment of the re-certification fee. The credential may not be used during the inactive period. Inactive status may only be used one time. Credentials are reactivated after the renewal requirements have been met and the application has been processed. Credentials are not backdated.TO COMPLETE THE APPLICATION:1. SAVE THIS DOCUMENT ON YOUR COMPUTER.2. TYPE IN THE INFORMATION REQUESTED IN THE SPACES PROVIDED. 3. AFTER YOUR APPLICATION IS COMPLETED SAVE IT AGAIN. 4. FINALLY, SEND IT, ALONG WITH THE REQUIRED DOCUMENTS, BY EMAIL TO AHNCC at recertification@ OR YOU MAY SEND IT BY MAIL.Process:Submit the application for inactive status including the appropriate fee. Complete recertification eligibility requirements within the three-year period.Submit the required materials for recertification as presented in the AHNCC recertification packet, including the recertification fee.Credentials will become active at the time recertification is approved.Fees:AHNA member: $100.00Regular/nonmember: $125.00AMERICAN HOLISTIC NURSES' CREDENTIALING CORPORATION:INACTIVE STATUS APPLICATION Please use the following checklist for your application for inactive status. An incomplete application will not be processed and may result in expiration of your certification.General Information and Checklist I am applying for inactive status for (choose one): HN-BC? FORMCHECKBOX HNB-BC? FORMCHECKBOX AHN-BC? FORMCHECKBOX APHN-BC? FORMCHECKBOX NC-BC? FORMCHECKBOX HWNC-BC? FORMCHECKBOX The renewal date for my current certification is ___________Checklist: FORMCHECKBOX Type information directly into the form FORMCHECKBOX Completed background information FORMCHECKBOX Signed Letter of Agreement. (Name can be typed on the Signature line.) FORMCHECKBOX Paypal receipt (or Signed check) for Inactive Status FORMCHECKBOX Retained a copy of all documents for your personal filesThis application packet must be completed in its entirety and submitted as a single set of documents to be processed. You may pay with PayPal.?($3.25 handling fee will be added)Send all documents as an email attachment to: recertification@Or mail to: AHNCC, 811 Linden Loop, Cedar Park, Texas 78613 Background InformationLegal Name: (Last) ___________ (First) ___________ (Middle) ___________ (Other Last Names Used ___________Social Security Number (Last four digits) ___________ AHNCC Certification Number (if known) ___________Address ___________ City ___________ State ___________ Zip ___________Telephone: (Home) ___________ (Work) ___________Cell phone ___________ Email ___________ Secondary email ___________Inactive Status fee paid by: Check # ____ ___ FORMCHECKBOX OR PayPal ($3.25 handling fee will be added) with receipt attached to these documents FORMCHECKBOX FEES: AHNA/NOVA/HMA Member$100.00Non-AHNA Member$125.00Check only one in each categoryPrimary Position Held: Academic faculty FORMCHECKBOX , Clinical Director FORMCHECKBOX , Administrator/VP FORMCHECKBOX , Clinical Nurse Specialist FORMCHECKBOX , Corporate Executive FORMCHECKBOX , Direct care staff FORMCHECKBOX , In-service FORMCHECKBOX , Staff development FORMCHECKBOX , Nurse manager FORMCHECKBOX , Nurse practitioner FORMCHECKBOX , Private practice FORMCHECKBOX , Other (specify) ___________ FORMCHECKBOX Highest Degree/Credential: Diploma FORMCHECKBOX , ADN FORMCHECKBOX , BS FORMCHECKBOX , BSN FORMCHECKBOX , MA FORMCHECKBOX , MEd FORMCHECKBOX , MSN FORMCHECKBOX , MS FORMCHECKBOX , DNSc FORMCHECKBOX , EdD FORMCHECKBOX , DNP FORMCHECKBOX , PhD FORMCHECKBOX , Other (specify) ___________ FORMCHECKBOX Employment Facility: College/University FORMCHECKBOX , Community College FORMCHECKBOX , Hospital/nonprofit FORMCHECKBOX , Hospital/profit FORMCHECKBOX , HMO Manage Care FORMCHECKBOX . Home Health FORMCHECKBOX , Clinic FORMCHECKBOX , Hospice, Non-academic FORMCHECKBOX , Self-employed FORMCHECKBOX , Other (specify) ___________ FORMCHECKBOX Current Employment:Month/Day/Year(s) ___________Primary Position ___________Title ___________ Address ___________ City ___________ State ___________ Zip ___________ Description of Duties (Describe how Holistic Nursing is incorporated into your current position: ___________ Candidate's Letter of Agreement with AHNCCI hereby apply for Inactive Status as a Holistic Nurse. I understand that Inactive Status extends the time I have to meet all eligibility criteria for recertification for up to three years. I further understand that the information acquired in the application process may be used for statistical purposes and for the evaluation of the certification program. I acknowledge that certification may be reactivated at any time during the three year period. Certification will only be reactivated upon completion of all of the current recertification requirements and payment of the re-certification fee. Recertification requirements may change at any time and it is the responsibility of the certificant to check the requirements before submitting their recertification application.I understand that there is no grace period or backdating for my certification and that it is my responsibility to check with my state licensing board or employer to determine if my expired certification credential affects my ability to practice. Certification renewal applications received after the certification expiration date will have a renewal date starting with the date of approval and certificants will therefore experience a gap in the certification dates. AHNCC does not backdate a certification renewal to meet regulatory, reimbursement, or other requirements for practice or employment. I understand it is my responsibility to find out whether I can continue to practice and/or receive reimbursement for services while I am in the process of reactivating my certification.To the best of my knowledge, the information supplied in this Application for Inactive Status is true, complete, correct, and is made in good faith. (Type your name between the / / in the Signature line, and repeat on the Name line.)Signature: ____/____________________________________________/__ Date ___________ ?Name: _____________________________________________________This application packet must be completed in its entirety and submitted as a single set of documents to be processed. You may pay with PayPal.?($3.25 handling fee will be added)Send all documents as an email attachment to: recertification@ .Or mail to: AHNCC, 811 Linden Loop, Cedar Park, Texas 78613FOR AHNCC OFFICE USE ONLY:HN-BC? FORMCHECKBOX HNB-BC? FORMCHECKBOX AHN-BC? FORMCHECKBOX APHN-BC? FORMCHECKBOX NC-BC? FORMCHECKBOX HWNC-BC? FORMCHECKBOX AHNA Member:? Yes FORMCHECKBOX No? FORMCHECKBOX ,?Membership # FORMTEXT ???????Date received; FORMTEXT ?????, Fee included by Check, FORMCHECKBOX Check # FORMTEXT ?????; OR Paypal FORMCHECKBOX , Receipt attached FORMCHECKBOX Approved By FORMTEXT ?????,?Date approved FORMTEXT ?????.Notes: ? FORMTEXT ?????This application packet must be completed in its entirety and submitted as a single set of documents to be processed. You may pay with PayPal.?($3.25 handling fee will be added)Send all documents as an email attachment to: recertification@Or mail to: AHNCC, 811 Linden Loop, Cedar Park, Texas 78613 ................
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