CPPN Application

Certified Professional Patient Navigator (CPPN) & Training 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
African AmericanNative AmericanAsian/Pacific IslanderCaucasian/WhiteHispanic/LatinoMultiracialOther
Preferred E-mail
Preferred Phone
Format: (000) 000-0000.
High SchoolAssociate DegreeBachelorsMastersDoctorateOther
Education Credential - File Upload(s) - picture or document of award/diploma

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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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Does Not ApplyLess than a year1-2 years3-6 years7 or more years
ColleagueConferenceEmployerPublicationWeb Search/SiteOther
Ethics Affirmation

Respond to each statement below.
YesNo
YesNo
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 "Reference" link to your references to support your application.

REFERENCE FORM
Reference Name:
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Affiliation
Reference Name:
Email
example@example.com
Phone Number
.Format: (000) 000-0000.
Affiliation
Experience Verification

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

VERIFICATION FORM
Payment Options

You will pay once you have met all credentialing requirements and have chosen your preferred billing option.
CPPN Exam - $400.00CPPN Exam Extended Payment (three payments of $135 each) - $405.00IPatient Navigation Professional Course- $1,500Professional Patient Navigation Lesson - $175 eachInvoice a third party (employer or other)
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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Certified Professional Patient Navigator (CPPN) & Training Application

Ethics Affirmation

References

Experience Verification

Payment Options