Get Certified Nursing Assistant Reciprocity Application

This guide is designed to assist you in completing the Certified Nursing Assistant Reciprocity Application online. By following the steps outlined below, you will ensure that your application is filled out accurately and efficiently.

Follow the steps to complete your application successfully.

1. Press the ‘Get Form’ button to access the application form and open it in your browser.
2. Begin by entering your personal information. Fill in your full name including last name, first name, and middle name. Provide your date of birth in the format MM/DD/YYYY.
3. Enter your mailing address where all correspondence and your license should be sent. If using a P.O. Box, include your physical location as well.
4. Provide your primary and secondary contact numbers. If you have utilized any other names, list them in the appropriate field.
5. Complete the Equal Opportunity Data section, providing demographic information as requested. This section is voluntary and does not impact your application.
6. In the current certification information section, input the state in which you are certified, your certification number, issue date, and expiration date.
7. Address the disciplinary history section truthfully. Answer all questions regarding any past denials, disciplinary actions, or surrender of a healthcare license.
8. Fill out the criminal history section, detailing any convictions or pleas of guilty to any crimes, except for minor traffic violations.
9. Complete the Medicaid and Medicare fraud section by answering the relevant questions regarding any felony convictions.
10. If applicable, provide information regarding your health history, including any treatments for drug or alcohol abuse or mental health issues.
11. Review all information you have entered for accuracy. It is essential that all questions are answered truthfully.
12. Sign the application in the designated space. Remember that your signature must be handwritten; the document cannot be submitted without it.
13. Finally, save your changes, and you will have the option to download, print, or share your completed application.

Complete your Certified Nursing Assistant Reciprocity Application online today to ensure a smooth application process.