Certification Exam Fee Reimbursement Program Application

Certification Exam Fee Reimbursement Program Application
For more infomration about eligibility and full requirement details, visit http://www.californiahia.org/exam-fee-reimbursement-program

Applications may be submitted anytime during the year, but must be received by CHIA within three months of passing the certification exam.
Name*

First NameLast Name
Credentials
AHIMA/CHIA ID Number*
CHIA Membership Status*

Student MemberGraduate MemberProfessional Member
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Email*
Certification Exam Detail
AHIMA’s HIM Certification Examination (select one)*

Registered Health Information Administrator (RHIA)Registered Health Information Technician (RHIT)Certified Coding Associate (CCA)Certified Coding Specialist (CCS)Certified Coding Specialist-Physician-based (CCS-P)Certified Health Data Analyst (CHDA)Certified Documentation Improvement Practitioner (CDIP)Certified Healthcare Technology Specialist (CHTS)
Exam Passed Date*

MonthDayYear
Exam Fee Amount Paid*
Name of College/University*
For RHIA, RHIT certification examinations only
Graduation Date*

MonthDayYear
Required Documentation
Documentation showing the date exam was successfully passed (PDF only)*

Upload a File

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Receipt verifying amount paid for exam (PDF only)*

Upload a File

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For RHIA, RHIT certification examinations only: Documentation showing the date of graduation from a CAHIIM-accredited HIA or HIT program (diploma, transcripts, etc) (PDF only)*

Upload a File

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I certify that the information submitted with this application is accurate and I authorize CHIA to validate its accuracy.*

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Certification Exam Fee Reimbursement Program Application

Certification Exam Detail

Required Documentation