"Application for Certified Medication Aide Payment Invoice" - Georgia (United States)

Application for Certified Medication Aide Payment Invoice is a legal document that was released by the Georgia Department of Community Health - a government authority operating within Georgia (United States).

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Healthcare Facility Regulation Division
Department of Community Health
APPLICATION FOR CERTIFIED MEDICATION AIDE
PAYMENT INVOICE
I wish to apply to become a certified medication aide (CMA) in Georgia. I understand that I must meet
all of the following requirements:
I must be a certified nurse aide (CNA) in good standing on the Georgia CNA Registry.
I must take and successfully complete the approved CMA training program which has been
administered by a Georgia-licensed physician, registered nurse or pharmacist.
I must pass a skills competency checklist for medications administered to me by the Georgia-licensed
physician, registered nurse or pharmacist.
I must also pass a written competency test that is administered through the Georgia Medical Care
Foundation website with a satisfactory score.
I must pay $25.00 to the Healthcare Facility Regulation Division, Department of Community Health, to
take the written competency test.
I understand that the fee of $25.00 is NOT REFUNDABLE, even if I do not pass the written
competency test.
DIRECTIONS FOR PAYMENT
1. COMPLETE AND PRINT THIS PAYMENT INVOICE FOR EACH CMA APPLICANT.
2. MAKE SURE YOUR CNA # IS CORRECT AND YOU HAVE INCLUDED YOUR MONTH AND
DAY OF BIRTH.
3. MAKE YOUR CHECK OR MONEY ORDER FOR $25.OO PAYABLE TO THE HEALTHCARE
FACILITY REGULATION DIVISION, DCH.
4. PUT YOUR CNA # ON THE CHECK OR MONEY ORDER IN THE MEMO FIELD TO ENSURE
PROPER CREDIT.
5. MAIL ONLY CHECK OR MONEY ORDER (NO CASH) AND THIS INVOICE TO:
HEALTHCARE FACILITY REGULATION DIVISION
P. O. BOX 741328
ATLANTA, GA. 30374-1328
YOU MUST PROVIDE ALL OF THE INFORMATION LISTED BELOW TO ENSURE THAT
YOUR PAYMENT IS PROPERLY CREDITED TO YOUR CMA APPLICATION.
(If you don’t know your CNA #, you can find it on this website:
https://www.mmis.georgia.gov/portal/PubAccess.Nurse%20Aide/tabId/71/Default.aspx)
FULL NAME:
(First Name, Middle Initial, Last Name—Must Be Same As Listed on CNA
Registry. If name has changed, contact CNA registry to change name there first)
ADDRESS:
CITY:
STATE:
Georgia
ZIP CODE:
PHONE NUMBER:
CERTIFIED NURSE AIDE #:
MONTH AND DAY OF BIRTH
(use
numbers 00/00):
CN
Healthcare Facility Regulation Division
Department of Community Health
APPLICATION FOR CERTIFIED MEDICATION AIDE
PAYMENT INVOICE
I wish to apply to become a certified medication aide (CMA) in Georgia. I understand that I must meet
all of the following requirements:
I must be a certified nurse aide (CNA) in good standing on the Georgia CNA Registry.
I must take and successfully complete the approved CMA training program which has been
administered by a Georgia-licensed physician, registered nurse or pharmacist.
I must pass a skills competency checklist for medications administered to me by the Georgia-licensed
physician, registered nurse or pharmacist.
I must also pass a written competency test that is administered through the Georgia Medical Care
Foundation website with a satisfactory score.
I must pay $25.00 to the Healthcare Facility Regulation Division, Department of Community Health, to
take the written competency test.
I understand that the fee of $25.00 is NOT REFUNDABLE, even if I do not pass the written
competency test.
DIRECTIONS FOR PAYMENT
1. COMPLETE AND PRINT THIS PAYMENT INVOICE FOR EACH CMA APPLICANT.
2. MAKE SURE YOUR CNA # IS CORRECT AND YOU HAVE INCLUDED YOUR MONTH AND
DAY OF BIRTH.
3. MAKE YOUR CHECK OR MONEY ORDER FOR $25.OO PAYABLE TO THE HEALTHCARE
FACILITY REGULATION DIVISION, DCH.
4. PUT YOUR CNA # ON THE CHECK OR MONEY ORDER IN THE MEMO FIELD TO ENSURE
PROPER CREDIT.
5. MAIL ONLY CHECK OR MONEY ORDER (NO CASH) AND THIS INVOICE TO:
HEALTHCARE FACILITY REGULATION DIVISION
P. O. BOX 741328
ATLANTA, GA. 30374-1328
YOU MUST PROVIDE ALL OF THE INFORMATION LISTED BELOW TO ENSURE THAT
YOUR PAYMENT IS PROPERLY CREDITED TO YOUR CMA APPLICATION.
(If you don’t know your CNA #, you can find it on this website:
https://www.mmis.georgia.gov/portal/PubAccess.Nurse%20Aide/tabId/71/Default.aspx)
FULL NAME:
(First Name, Middle Initial, Last Name—Must Be Same As Listed on CNA
Registry. If name has changed, contact CNA registry to change name there first)
ADDRESS:
CITY:
STATE:
Georgia
ZIP CODE:
PHONE NUMBER:
CERTIFIED NURSE AIDE #:
MONTH AND DAY OF BIRTH
(use
numbers 00/00):
CN