Approved Provider Intent to Apply/Eligibility Verification

Approved Provider Intent to Apply and Eligibility Verification
Section 1: Demographic Data
Organizations interested in submitting an application for approval or renewal of approval as an Approved Provider must complete meet all eligibility requirements. Verification forms received from organizations that do not meet eligibility requirements will be rejected without substantive review.
Organization Name:*
Organization Street Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization Type:*
To determine your organization type, visit this link: Approved Provider Organization Types and Fee Information
YesNo
Please enter your Approved Provider #:

Section 2: Nurse Planners
YesNo
YesNo
Primary Nurse Planner Name:*

First NameLast Name
Primary Nurse Planner Credentials:*
Please include all educational degree(s), certification(s), and license(s)
Primary Nurse Planner Job Title/Position in Organization:*
Primary Nurse Planner RN License Number:*
Primary Nurse Planner State of Licensure:*
Primary Nurse Planner Email:*
example@example.com
Primary Nurse Planner Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Please list the names and credentials of all current Nurse Planners. If the Primary Nurse Planner is the sole Nurse Planner, please indicate this below.*

Section 3: Regional Target Market
YesNo
For region information, refer to https://www.hhs.gov/about/agencies/iea/regional-offices/index.html.

Based on the responses provided, the applicant organization is not eligible to be an Approved Provider but may be eligible to apply as an Individual Activity Applicant. For more information about that process, please visit our website.

If you believe this to be a mistake, you may return to the form to review and update your responses or email VNA's Accredited Approver Program Director, Kate Hildreth.

Section 4: Eligible Operations

The applicant organization must answer the following questions and provide any additional required information.
YesNoNot yet but will be at time of application.
Please list the date the organization became operational or will become operational:*

MonthDayYear
Date
The applicant has assessed, planned, implemented, and evaluated at least three (3) separate educational activities, within the past 12 months, provided at separate and distinct events, with the direct involvement of one of the Nurse Planners listed above and adhere to the ANCC Accreditation Program Criteria. If applying as a NEW applicant, each learning activity must be at least 1 hour (60 minutes) in length, contact hours may or may not have been offered, and the activities not jointly provided.*

YesNoRenewing applicant with less than three activities in the past year.
YesNo

Based on the responses provided, the applicant organization is not eligible to be an Approved Provider.

If you believe this to be a mistake, you may return to the form to review and update your responses or email VNA's Accredited Approver Program Director, Kate Hildreth.

Section 7: Statement of Understanding
I attest, by my signature below, that I am duly authorized by {nameOf} to submit this application as an approved provider offered by the American Nurses Credentialing Center (ANCC) through Accredited Approvers and to make the statements herein. On behalf of {nameOf}, I have read the approved provider eligibility requirements and criteria. I understand that the {nameOf} 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 {nameOf}, 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 {nameOf}’s permission.

On behalf of {nameOf}, I hereby certify that the information provided on and with this application is true, complete, and correct. I further attest, by my signature on behalf of {nameOf}, that {nameOf} will comply with all eligibility requirements and approval criteria throughout the entire approval period, including all reapplication periods for maintaining approval, and that {nameOf} will notify Virginia Nurses Association promptly if, for any reason while this application is pending or during any approval period, {nameOf} 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 Virginia Nurses Association to deny, suspend or terminate {nameOf}’s approved provider status and to take other appropriate action against {nameOf}.
The box below serves as the electronic signature of the individual completing this form and attests to the accuracy of the information contained.*

Clear
Completed by:*

First NameLast Name
Title:*
Date*

MonthDayYear
Date
Invoicing Information
By submitting this form, I attest that I understand it is my responsibility to contact my organization's accounting department to determine what is needed for timely payment of Approved Provider invoicing. Specific payment details must be sent to khildreth@virginianurses.org. Approved Provider invoices will be sent six months prior to application due date.
Accounting Department Contact Information:*

First NameLast Name
Accounting Department Email Address:*
example@example.com
Accounting Department Phone Number:*
Format: (000) 000-0000.
Should be Empty:

Approved Provider Intent to Apply and Eligibility Verification

Section 1: Demographic Data

Section 2: Nurse Planners

Section 3: Regional Target Market

Section 4: Eligible Operations

Section 5: Ineligible Company

Section 6 - Applicant Organization is NOT Exempt

Section 7: Statement of Understanding

Invoicing Information