CPPN Application

Certified Professional Patient Navigator (CPPN) Application

Patient-Centered Education & Research Institute is a member of the Institute for Credentialing Excellence.
Applicant Name*

First NameMiddle NameLast Name
Gender
Birth Date

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ethnic/Racial Identity

African AmericanNative AmericanAsian/Pacific IslanderCaucasian/WhiteHispanic/LatinoMultiracialOther
Preferred E-mail
Preferred Phone
Highest Level of Formal Education*

High SchoolAssociate DegreeBachelorsMastersDoctorateOther
Education Credential - File Upload(s)

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Licensure/Certification

Advance Practice Registered NurseCertified Medical Assistant/TechnicianLicensed Professional NurseMental Health ProfessionalPhysician AssistantPhysicianRegistered NurseSocial WorkerNot Licensed/CertifiedOther
Current License Title (If Applicable)
Licensing Organization
License Number
Issue Date
Licensure & Certifications Upload(s)

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Current Resume*

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How many years of patient navigation experience do you have?

Does Not ApplyLess than a year1-2 years3-6 years7 or more years
How did you learn about this certification?

ColleagueConferenceEmployerPublicationWeb Search/SiteOther
Ethics Affirmation

Respond to each statement below.
Have you ever been or are you currently charged with any criminal offence?

YesNo
Have you ever been or are you currently named in a civil or other legal action?

YesNo
Have you or are you currently the subject of any public or private professional complaint, investigation or disciplinary action, including licensure board or professional membership matters?

YesNo
If you answered "yes" to any of these, include an explanation here and a summary of outcomes. If you have relevant documents, submit copy(ies) below. An affirmative response does not preclude certification.
Ethical Issues Documentation (If any)

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References

Please copy and forward the PCERI-CPPN "Reference" link to your references to support your application.

https://form.jotform.com/231666812233151
Reference Name:
Email
example@example.com
Phone Number
Affiliation
Reference Name:
Email
example@example.com
Phone Number
.
Affiliation
Experience Verification

Please copy and forward the PCERI-CPPN "Experience Verification" link to current and/or previous employers/supervisors who can certify your experiences in healthcare and patient navigation:

https://form.jotform.com/231665957237164
CPPN Payment

You will pay once you have met all credentialing requirements and have chosen your preferred billing option.
CPPN Preferred Payment Option (you will not be charged here)

CPPN Exam - $400.00CPPN Exam Extended Payment (three payments of $135 each) - $405.00PCERI Patient Navigation Professional Course (PNPC) Completer - $300.00Invoice a third party (employer or other) - $400.00Invoice a third party (employer or other) PNPC Completer - $300.00
I attest that all information I provided in this application is complete and accurate. I agree that PCERI has the right to contact all persons and organizations cited in this application for verification purposes. I understand that these application materials become the property of PCERI. I understand that my certification depends upon my fulfillment of all criteria and policies of PCERI. I understand PCERI Certification is personal to me and may not be transferred to another individual or group. I recognize that any certification granted by PCERI does not represent licensure or other authorization to practice business activities for a fee. I release PCERI from all liability and claims arising from my professional activity. Electronic signature is authorized. *

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Should be Empty:

Certified Professional Patient Navigator (CPPN) Application

Ethics Affirmation

References

Experience Verification

CPPN Payment