APPROVED PROVIDER INTENT TO APPLY/

ELIGIBILITY VERIFICATION

Thank you for your interest in applying for Approved Provider status through the Midwest Multistate Division. Organizations interested in applying to become an Approved Provider must complete the eligibility verification process, meet all eligibility requirements and submit a $200 intent-to-apply fee. The Midwest Multistate Division is responsible for ensuring that the applicant is eligible to apply.

æ 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]. Return completed forms to . Please save an electronic copy of the completed document for your files.

æ 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. The intent-to-apply fee will be credited toward the provider application review fee for organizations that proceed forward with the full Provider Application.

æ 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.

æ 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 or 573-636-4623, ext. 102 with questions.

The Midwest Multistate Division is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

DEMOGRAPHICS

Name of Applicant Organization:
New applicant – / Year you intend to apply to the Midwest MSD for Approved Provider status:
Current Provider – / Provider Approval Number:
Approved by:
Approval expiration date:
Which review cycle? / February / June / October
Example: February Review cycle (application deadline February 1; approval decision finalized by June 1)
Type of Applicant: / Single Agency Provider / System Provider (Questions? Please see Application Instructions)
Renewal Applicant / First time Applicant
Mailing Address:
(Address, City, State, ZIP)
Contact Person: / Title/Position:
Email Address: / Daytime Phone:

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ELIGIBILITY VERIFICATION

To be eligible to apply for Approved Provider status, an organization must:

1. Have a clearly defined ‘provider unit’ or department administratively and operationally responsible for continuing nursing education. An Approved Provider Unit (APU) is defined structurally and operationally as the members of the organization who support the delivery of Continuing Nursing Education (CNE) activities.

My provider unit is:
A free-standing organization whose purpose is only to offer continuing education programs for nurses (single-
focused organization) e.g. a continuing education company
Part of an organization that does other things besides offer continuing education programs for nurses (multi-
focused organization) e.g. a hospital, college or university
If your organization is multi-focused, is there a separate, clearly defined ‘provider unit’ administratively and operationally responsible for planning, implementing, and evaluating continuing nursing education?
YES
NO – Please stop and contact the Midwest MSD Office to discuss eligibility.

2. 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 continuing nursing education.

Identify the PNP responsible for adhering to ANCC/Midwest MSD accreditation criteria in the provision of CNE.
Name and Credentials:
Title/Position:
Preferred Phone:
Email Address:
All Nurse Planners are currently licensed Registered Nurses with a baccalaureate degree or higher in nursing.
YES
NO – Please stop and contact the Midwest MSD Office to discuss eligibility.
Nurse Planners are (1) actively involved in planning all CNE activities from start to finish; (2) knowledgeable about the nursing CE process; and (3) meet the qualifications to hold this position.
YES
NO – Please stop and contact the Midwest MSD Office to discuss eligibility.

3. Limit their marketing promotion or advertisement of continuing nursing education (CNE) to nurses in either their local DHHS region or a state contiguous to that single region (click here for HHS region map). Less than 50% of the organization’s programs are marketed to nurses outside of their region or a state contiguous to that region.

If you target 50% or more of your programs to nurses outside of your region or a state contiguous to that region, you 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, the organization targeted (marketed/promoted/advertised) more than half of its CNE programs to nurses within your local DHHS region or a state contiguous to this region.

YES
NO – Please stop and contact the Midwest MSD Office to discuss eligibility.

4. Not meet the definition of a commercial interest:

A ‘commercial interest’, as defined by ANCC, is any entity producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patients, or an entity that is owned or controlled by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on patients. Nonprofit or government organizations, non-healthcare-related companies, and healthcare facilities are not considered commercial interests.

Does your organization produce, market, re-sell, or distribute health care goods or services consumed by, or used on, patients?

NO
YES– You are only eligible to apply IF you identify your organization as one of the following:
Hospital, long-term care facility, or rehabilitation center; for-profit or nonprofit
Nonprofit organization or professional association
College or University
Constituent Member Association or Specialty Nursing Organization
National nurses organization based outside the United States
Government organization
Blood bank
Diagnostic laboratory
Federal Nursing Service
Group medical practice
Health insurance provider
Liability insurance provider
Non-health care related company
Provider of healthcare information technology
Single-focused organization devoted only to providing continuing nursing education
NO - NONE OF THE ABOVE – Please stop and contact the Midwest MSD Office to discuss eligibility.

* If you checked ‘YES’ and have not identified your organization as one of the types above, you may not be eligible to apply. Please contact the Midwest MSD Office before proceeding.

5. Comply with all applicable federal, state, and local laws and regulations that affect the organization’s ability to meet ANCC/Midwest MSD accreditation criteria and requirements.

The organization is in compliance with all applicable federal, state, and local laws and regulations that affect the organization’s ability to meet ANCC/Midwest MSD accreditation criteria and requirements.
YES
NO – Please stop and contact the Midwest MSD Office to discuss eligibility.

RENEWAL 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 B
NO – 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 eligibility
NO – proceed to Question C
C. The organization has planned, implemented, and evaluated at least three educational activities that:
X / directly involved a designated Nurse Planner
X / adhered to ANCC/Midwest MSD accreditation criteria
X / were at least one contact hour in length; and,
X / were not jointly provided.
YES – proceed to Statement of Understanding
NO – Please stop and contact the Midwest MSD Office to discuss eligibility.
D. Proceed to Statement of Understanding

FIRST TIME 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 B
NO – Please stop and contact the Midwest MSD Office to discuss eligibility.
B. The organization has planned, implemented, and evaluated at least three educational activities that:
X / directly involved a designated Nurse Planner
X / adhered to ANCC/Midwest MSD accreditation criteria
X / were approved by the Midwest MSD Approver Unit or another ANCC Accredited Approver in the past year
X / were at least one contact hour in length; and,
X / were not jointly provided.
YES – proceed to Question C
NO – 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 Understanding

STATEMENT OF UNDERSTANDING

I 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: An ‘X’ in the box below serves as the electronic signature of the Primary Nurse Planner.

Name and Credentials: / Date:
Position/Title:

OFFICE USE ONLY

Date Eligibility Form Received:
Eligible to Apply for Approved Provider Status:
YES / Decision Made by:
NO / Date:
Comments:
Assigned to which review cycle? / February / June / October / Year:
Organization contacted the Midwest MSD Office to discuss eligibility.
Date Contacted:
Plan for Follow-up:
Date Organization Notified:

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