RN SPECIALITY CERTIFICATION OR RECERTIFICATION REIMBURSEMENT FORM

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This form covers RN Specialty Certification/Recertification activities completed in the current year. Activities completed in the previous year cannot be reimbursed after December 31st of that year.

(Activities completed in the current year and paid for in the previous year can be reimbursed using this form. For example, if you paid for your certification exam in 2020, but did not take the test till 2021 you can still use this form to be reimbursed out of your 2021 benefit based on your eligibility).

For program details, eligibility, specialty nurse areas, and other details, please visit the professional development page of our website.

Supporting documentation is necessary:

Proof of Payment/Costs: detailed invoice/receipt with certifying organization name, your name, the exam/certification name you are pursuing, the date paid and the total paid.
Proof of Certification/re-certification/exam results: a copy of your certification or letter from the organization recognizing your certification/re-certification.

For exams: you DO NOT have to pass your exam to be reimbursed! In the case you are needing reimbursement for an exam that you did not pass, you need only send us the proof of payment/costs and proof you took the exam from the organization (a copy of your test results will usually suffice along with a receipt of payment).

The standard processing time once all standard backup documentation received is 30 Days.

You must have your backup documentation ready to upload before continuing.

Yes I have my backup documentation ready to upload

NOTE: PER DIEM & CONTRACT EMPLOYEES ARE NOT ELIGIBLE FOR THIS SERVICE

This form covers activities completed in the current calendar year. Activities completed in the previous year cannot be reimbursed after the December 31st deadline.

(Activities completed in the current year but paid for in the previous year can still be reimbursed using this form).

EMPLOYEE INFORMATION (your name should match what your employer has, no nicknames please)

First Name

Middle Initial

Last Name

Mailing Street

Mailing City

Mailing State

Mailing Zip/Postal

Preferred Phone Number

Mobile Phone

Work Phone

Home Phone

Primary Email

Email (please be sure you DO NOT share this email with another hospital worker such as a family/friend/co-worker/spouse/child - each person needs to have their own email and you can always use your work email if you don't have a personal email)

Employer

Worksite Location/Campus (if not at a main hospital bldg. ex. SMC Capital Hill, VMC Kent Clinic, Lidgerwood KP, etc.)

Department

Job Title

Bargaining Unit

Current FTE

Date of Hire (mm/dd/yyyy format)

Professional Development Information

I am requesting reimbursements for

Name of certification or recertification

Start date of certification

End date of certification

Sponsoring/certifying organization (this would be the name organization that you paid for the certification exam/re-certification costs)

Total dollar amount requested (no $ sign please, just the numbers. Ex. "220.25")

No $ necessary

Date Purchased/Paid For

Lead Source

Record Type

Opportunity Name

Opportunity Stage

Required Supporting Documentation:

Certification or Recertification by exam:
All applicants must show proof of payment & cost and proof of completion for reimbursement. A copy of your new certification showing a new expiration date or your test results are sufficient.

Proof of Payment & Cost:
Please submit a valid invoice receipt from the organization you applied for your certification through. The invoice will show the organizations name, your name, the date of payment, the total amount paid (including fees) and a detailed description of what you paid for.

Proof of Completion:
You must submit a document showing that you completed the exam. This must show the name of the sponsoring organization, as well as your name, and the name of the certification. You may be reimbursed for your exam costs regardless of whether you pass or fail.

Recertification by any means other than exam:
You must submit documents showing proof of payment and evidence of recertification in your name. Your proof of payment must include your name, the name of the sponsoring organization that was paid, the amount paid, and the date paid.

Backup Documentation

On the Next Page you will be able to review everything you are about to submit to the Training Fund. Please be sure your contact information is accurate and the supporting documentation has been uploaded. When you have submitted your request, within a few minutes, you will receive an email from William Coyle via Conga Sign to sign your funding request. If you do not receive that email (it may go to junk or spam) or have any questions about the electronic signing process please contact us at 425-255-0315 or members@healthcareerfund.org.

Under penalty of perjury, I state that the information provided is correct. By signing this form, I approve the Training Fund to issue funding on my behalf.

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