AHNCC Inactive Status Handbook Application Packet

AHNCC Inactive Status Handbook Application Packet

Interactive Form

THE AMERICAN HOLISTIC NURSES

CREDENTIALING CORPORATION

APPLICATION FOR INACTIVE STATUS

FOR

AHNCC CERTIFIED REGISTERED NURSES

(Holistic Nurses and Nurse Coaches)

January 29, 2016, May 11, 2016, May 1, 2017, June 16, 2017, September 21, 2017, February 9, 2018

Introduction

Certified 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 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: $100.00
• Regular/nonmember: $125.00

AMERICAN 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® HNB-BC® AHN-BC®
APHN-BC® NC-BC® HWNC-BC®

The renewal date for my current certification is ______

Checklist:

Type informationdirectly into the form

Completed background information

Signed Letterof Agreement.

Paypal receipt (or Signed check) for Inactive Status

Retained a copy of all documents for your personal files

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.(includes $3.25 handling fee)

Send all documents as an email attachment to:

Or mail to: AHNCC, 811 Linden Loop, Cedar Park, Texas 78613

Background Information

Legal Name: (Last) ______(First) ______(Middle) ______(Maiden) ______

Social Security Number (Last four digits) ______AHNCC Certification Number ______

Address ______City ______State ______Zip ______

Telephone: (Home) ______(Work) ______Cell phone ______FAX ______

Email ______Secondary email ______

Inactive Status fee paid by: Check # ______OR

PayPal(includes $3.25 handling fee) with receipt attached to these documents

FEES:

AHNA Member$100.00

Non-AHNA Member$125.00

Check only one in each category

Primary Position Held:Academic faculty, Clinical Director, Administrator/VP , Clinical Nurse Specialist , Corporate Executive , Direct care staff , In-service , Staff development , Nurse manager , Nurse practitioner , Private practice , Other(specify) ______

Highest Degree/Credential:Diploma , ADN , BS , BSN , MA , MEd ,

MSN , MS , DNSc , EdD , DNP , PhD , Other(specify) ______

Employment Facility:College/University , Community College , Hospital/nonprofit , Hospital/profit , HMO Manage Care . Home Health , Clinic , Hospice, Non-academic , Self-employed , Other (specify) ______

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 AHNCC

I 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 myexpired 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.(includes $3.25 handling fee)

Send all documents as an email attachment to:

Or mail to: AHNCC, 811 Linden Loop, Cedar Park, Texas 78613

FOR AHNCC OFFICE USE ONLY:

HN-BC® HNB-BC® AHN-BC® APHN-BC® NC-BC® HWNC-BC®

AHNA Member: Yes No,Membership #

Date received; , Fee included by Check, Check # ; ORPaypal , Receipt attached

Approved By,Date approved .

Notes:

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.(includes $3.25 handling fee)

Send all documents as an email attachment to:

Or mail to: AHNCC, 811 Linden Loop, Cedar Park, Texas 78613

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