American Board of Managed Care Nursing
APPLICATION TO SIT FOR CMCN / CMCP EXAM

I Will Be Working With My Own Proctor
OR
For the application to sit the exam for an additional $25
 with ExamRoom.AI Remote Proctoring
or at the Managed Care Forum
 please click here.


 

 


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1. Applicant Information  (*=Required Field)
Last Name For Certificates:*  
First Name For Certificates:*  With Middle Initial if Desired
Last Name on License:
(If different from above)		  
First Name on License:
(If different from above) 		 With Middle Initial if Desired
Title*:  
Organization:*  
Address:*  
City:*   
State:*  
Zip:*  
Address is:*  Organization  Home
Education/Degrees Acquired:*

 RN   LVN      LPN    LCSW    MCSW  LPC  MD  PA
Other Credentials:
Phone:*  
Email:*  
Specialty:  
 Last 4 digits of your SSN:*  
License Number:  
State of Licensure:  
My current license can be found at this website:  
Years of Experience in managed care:  
2. Payment
  Certification Examination Fee is $250.00  (I will be working with my own proctor)
If Paying by Check, Check #:   (Payable to ABMCN)
When you provide a check as payment, you authorize us either to use information from your
check to make a one-time electronic fund transfer from your account or to process the
payment as a check transaction.
 
If Paying with Credit Card:   To pay by credit card please click submit at bottom of page
If you are paying by credit card and the cardholder name is different than applicant name
above, please enter cardholder name here: 
 
3. Affidavit

I completed and submitted my post test of the  American Association of Managed Care Nurses  Preparatory course
Signature:
Date:
The Name of My Proctor for the Examination is:
My Proctor's Phone Number:
Proctor Application*:  Will be faxed to 804-747-5316        Will be emailed to jbeilhart@abmcn.org
Request Exam Format*:   Paper     Online

4. Authorization

  I authorize the American Board of Managed Care Nursing (ABMCN) to use whatever it deems necessary to verify the statements I have made to the ABMCN. I accept that the ABMCN will treat all information regarding this form and my certification as confidential. I allow the ABMCN to use the data on this, or the examination, for statistical analysis and improvement of the ABMCN examination process. I declare all statements in my application are true and that to utter a false statement is grounds for denial or loss of the CMCN / CMCP credential.
I authorize the ABMCN to send by US mail my test results IN THE FORM OF PASS OR FAIL to the above address.
 
Signature:
Date:
 

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If this application form is incomplete or if any required documentation is missing, your application will be returned to you.


 You will need to fax or email (jbeilhart@abmcn.org) the completed Proctor Agreement Form and a copy of your current nursing license (if you have not provided a web address of where your nursing license can be verified online) within 24 hours.


ABMCN, Application Department
4435 Waterfront Drive, Suite 101
Glen Allen, Virginia 23060, Tele 804/527-1905
Fax: 804/747-5316
jbeilhart@abmcn.org