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COPA: Third-Party Payment Request Form
Thank you for supporting your workforce by paying the application or recertification fees for your Certified Peer and Family Specialist (CPFS) and/or Colorado Certified Prevention Specialist (CCPS) applicants.Use this form if your organization is submitting payment on behalf of one or more employees or applicants. Please provide complete and accurate information for your organization and each applicant to ensure payments are applied correctly. Before submitting this form: Verify that each applicant's legal name and email address exactly match their Certemy account. Double-check your payment calculations using the fee schedule provided. Please note: Third-party payment requests are processed on Fridays. Once this form is submitted, COPA will review the information and send an invoice via email to the designated payee. After payment has been received and verified, COPA staff will apply the payment to each applicant's Certemy account. Processing may be delayed if additional information is needed.Thank you for investing in Colorado's behavioral health workforce.
Name of the employer or organization paying the application fee(s).
*
First Name
Last Name
Name of Employer/Organization Paying the Fees
Name of the person submitting this payment request.
*
First Name
Last Name
Complete mailing address of the organization.
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email address for payment confirmation and questions.
*
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Payment method.
*
Credit Card
Check
Total Payment Amount (USD).
*
CPFS/CCPS Initial Application: $245 application fee + $50 registration fee = $295 per applicant.CPFS/CCPS Recertification: $200 application fee per applicant.Please Note: Initial application fees include one examination attempt. Exam retakes require an additional fee
For each applicant, provide:
*
• Legal name (must match Certemy account) • Credential (CPFS or CCPS) • Application Type (Initial or Recertification)
Additional Notes
Include any information that may assist COPA in processing your request.
I certify that the information provided is accurate and that the listed applicants have authorized our organization to pay their CPFS/CCPS application or recertification fees.
Yes
No
Submit Request
Applicant's Email Address
example@example.com
Date sent to accounting
-
Month
-
Day
Year
Date
Date proof of payment uploaded to Certemy
-
Month
-
Day
Year
Date
Any special notes
Should be Empty: