The American Registry of Medical Assistants

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Prequalification

PRE-QUALIFICATION FORM

THIS IS NOT AN APPLICATION.

THIS IS A PRE-QUALIFICATION FORM WHICH WE REVIEW FOR YOUR ELIGIBILITY TO APPLY.

DO NOT PRINT THIS FORM.

DO NOT INCLUDE DOCUMENTS OR FEE WITH THIS FORM.

DOCUMENTS SUBMITTED WITH THIS FORM ARE NOT REVIEWED.
THEY ARE SHREDDED.

Qualified applicants are considered for registration and certification without regard to race, color, national origin, religion, sex, age, marital status, medical condition or handicap.

Once the pre-qualification form has been reviewed and you are eligible to apply, you will be sent an application to the address you provided.

Please be advised:
APPLICATION FEES ARE NON-REFUNDABLE.

First Name
Middle Name		Last Name
Address	(please include apt. #)
City
State
Zip		Phone
		Date of Birth
Email
Last Four Digits of SS		Review Number (if you have one)

Education High School

Did you graduate from an accredited High School? Yes No N/A

School Name:

Location:

Year of Graduation:

If No, did you obtain your GED?

Yes No N/A

Facility Name:

Location

Year you obtained your GED:

Disclosure

Have you ever been convicted of a felony or misdemeanor? Yes No N/A

Juvenile misdeameanor charges or convctions processed through the juvenile court system are not required to be reported to ARMA. Traffic charges, without a related drug / alcohol charge, are not required to be reported to ARMA.

A conviction of; a plea of guilty to; or a plea of nolo contendere to an offense constitutes a conviction for ARMA purposes.

Brief Synopsis:

If you are eligible to apply, convictions, which have been formally cleared as evidenced by a letter or statement from an official source to that effect, must be submitted with your application. (Once becoming a member of ARMA, convictions previously reported to ARMA may be entered as NO for future forms).

MILITARY PERSONNEL: If you are in (or have been recently discharged from) the USA military
Do you have a copy of your Medic/Corpsman school transcripts/military course completions (SMART/AARTS/ACE)?	Yes No N/A
Do you have a copy of your diploma/certificate of completion from Medic/Corpsman program?	Yes No N/A
Do you have a letter of recommendation from your Commander/Department Head?	Yes No N/A
If not, do you have a copy of your recent discharge papers?	Yes No N/A
What date were you discharged?
Do you have a copy of your military ID or state issued driver s license?	Yes No N/A
Military personnel, please go to end of form and read additional application information .

EDUCATION - Continuing / Other

Did you attend an accredited institution of medicine , nursing or medical assisting ?

Yes No N/A

Institution name:

Location:

Year of graduation:

Degree Title/Program granted:

If you did not graduate, how many semesters did you complete?

How long have you been working as a Medical Assistant?

N/A

If not working at present, how long since you last worked as an MA?

List the last 3 (if applicable) places you have worked as a medical assistant (facility name, location, dates of employment)

How long have you been working as a Physician or Nurse? N/A

If not working at present, how long since you last worked as a Physician or Nurse? N/A

List the last 3 (if applicable) places you have worked as a Physician or Nurse (facility name, location, dates of employment)

Documentation to be submitted for review

Do you have a copy of your diploma from an accredited medical , nursing or medical assisting institution?

Do you have a copy of your transcripts from an accredited medical , nursing or medical assisting institution?

If a graduate of a foreign institution, is your diploma translated?

If a graduate of a foreign institution, are your transcripts translated?

*Legible copies of these two forms of valid identification are required. Both identifications must bear the applicant's signature (Social Security Card, from the USA Social Security Administration, with your signature AND Photo Identification with your signature - unexpired state issued driver's license, state or federal issued identification card, or passport).

*Do you have these two forms of valid ID with your signature? (social security card with your signature AND unexpired government issued photo ID with your signature ).

If there are any discrepancies between your valid ID and your diploma and transcripts; letter of recommendation; and/or work history, do you have legal documentation to substantiate the discrepancy (birth, marriage, divorce certificate)?

If in a language other than English, is your documentation translated?

Do you have an official letter of recommendation from your physician employer, on original facility letterhead , stating dates of employment, specific clinical and clerical duties performed and the physician s determination you are qualified to be a traditional medical assistant. (This letter must include the physician s signature and medical license number, as this is an official letter of recommendation). Notes written or typed on plain copy paper will not be accepted. The letter must be official .

If in a language other than English, is the letter translated?

If you do not have a letter of recommendation from your physician employer, do you have an official letter from the Human Resource Department of a major medical facility, stating your length of employment and a copy of the official posted job description for your position?

If in a language other than English, is the letter and documentation translated?

If you do not have the above-mentioned necessary recommendation documentation, do you have a copy of your recent official work history documentation from your country of origin?

If in a language other than English, is your work history documentation translated?

TRADITIONAL MEDICAL ASSISTING DUTIES PERFORMED . These are the duties you PERFORM on a daily basis. DO NOT include œknowledge of aspects of medical assisting. Doing so is a disservice to your place of employment; to the physicians, nurses and support staff with whom you work; to the patients you attend; to the medical community and, most of all, to yourself.

LIST ALL CLERICAL DUTIES AND RESPONSIBILITIES PERFORMED:

LIST ALL CLINCAL DUTIES AND RESPONSIBILITIES PERFORMED:

Your diploma, transcripts, letter of recommendation and/or official job description and/or work history submitted for final review must accurately correspond with what you have submitted for pre-qualification review. If your application and documentation submitted for final review does not correspond with the pre-qualification form you submitted for review, you will be rejected and you will forfeit your application fee.

*Have you read the above statement? Yes No

PLEASE READ THE FOLLOWING FOR ADDITIONAL INFORMATION REGARDING THE ARMA APPLICATION PROCESS

All forms are reviewed in the order they are received. DO NOT call or email to question the progress of your pre-qualification review. This action will just delay your review process.

After review of your pre-qualification form, ARMA will contact you with confirmation of eligibility or your ineligibility to apply.

If you are eligible to apply, ARMA will send you an original application. ARMA will also send you a confirmation notice listing the stated information you entered on your pre-qualification form. When you submit your signed and dated application with all required documentation and the non-refundable $65.00 application fee (money order or credit card) for final review, also include your signed and dated confirmation notice.

If you are ineligible to apply, ARMA will contact you indicating the necessary documentation needed to comply with the pre-qualification requirements. All ineligibility information is entered into a review database for cross-reference purposes. When you obtain the necessary documentation, complete the pre-qualification form again. ARMA will review your updated pre-qualification form for eligibility to apply.

If you have falsely or inaccurately answered any of the pre-qualification questions and you submit an inaccurate or incomplete application for final review, you will forfeit your application fee. If you have neglected to include all required documentation for final review, you will forfeit your application fee. You will receive a rejection notice stating the reason(s) for rejection. All rejected information will be entered into a reject database for cross-reference purposes. Your rejected application will be held for 2 months from your rejection date. If ARMA has not received the required documentation listed on your rejection notice, the signed and dated rejection notice and the additional $30.00 re-application fee within the 2 months, your application and all contents will be destroyed.

If you neglected to sign and date your application submitted for final review, you will forfeit your application fee. Your rejection notice will be sent to you with a signature sheet. All rejected information will be entered into a reject database for cross-reference purposes. Your documentation will be held for 2 months from rejection date. If ARMA has not received your signed and dated signature sheet, rejection notice and the additional $30.00 re-application fee within the 2 months, your documentation will be destroyed.

Once you receive your application and confirmation notice: If you have any questions regarding what you are to submit for final review, we highly suggest you contact ARMA BEFORE you mail your application.

APPLICATION FEES ARE NON-REFUNDABLE

* HAVE YOU READ THE ABOVE INFORMATION? Yes No

All policies, procedures and criteria are subject to change and may occur without notice.

Thank you for completing this Pre-qualification form.

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The American Registry of Medical Assistants
69 Southwick Road, Westfield, MA 01085, USA
Phone: 413.562.7336