«CALIFORNIA CERTIFYING BOARD FOR MEDICAL ASSISTANTS A Private Non-Profit Corporation PO Box 462 Placerville CA 95667 (530) 622-1850 Email: ...»
CALIFORNIA CERTIFYING BOARD FOR MEDICAL ASSISTANTS
A Private Non-Profit Corporation
PO Box 462 Placerville CA 95667 (530) 622-1850
Email: firstname.lastname@example.org Website: www.ccbma.org
CALIFORNIA CERTIFIED MEDICAL ASSISTANT
PLEASE PRINT LEGIBLY FAXED OR EMAILED APPLICATIONS WILL NOT BE ACCEPTEDLEGAL NAME (Must EXACTLY match your United States government issued ID): Name change requests after submission of the application are subject to a $40 fee.
First Middle Last Mailing Address______________________________________________________________________
Number Street Apt# City State Zip Zip Telephone:__________________________________________________________________________
Home Cell Work Date of Birth_________________Email___________________________________________________
**Applicants must be 18 years of age and provide proof of a valid US government issued ID or Driver’s License and current CPR certification.** INITIAL EXAMINATION FEES NOTE: CLINICAL CERTIFICATION will require proof (Fees are subject to change without notice) of injection and/or venipuncture training as ___Basic and Clinical Specialty $ 145 outlined in the California Medical Assistant ___Basic and Administrative Specialty $ 145 regulations:
___Basic, Clinical & Administrative Specialties $ 185
A) Ten (10) clock hours in administering injections and performing skin tests including satisfactory AFTER INITIAL EXAMINATION FEES performance of at least ten (10) each of (Fees are subject to change without notice) intramuscular, subcutaneous, and intradermal ___Second Specialty – Administrative $ 90 injections and ten (10) skin tests and/or ___Second Specia
ELIGIBILITY REQUIREMENTSAn applicant for the California Certified Medical Assistant exam must satisfy at least one of the following requirements AND must provide proof of current CPR certification Currently employed as a medical assistant by a licensed physician (MD/DO) or podiatrist (DPM) in
the United States:
Employer’s Name: _____________________________________Phone:______________________
Address: __________________________________________Job Title: ____________________________
(Attach verification of employment, such as a copy of your pay stub or physician-employer signed statement on office letterhead).
OR Graduate of an accredited medical assisting program* in the United States within one year preceding
Name of School: ________________________________________________________________________
(You must provide a copy of your Certificate of Completion from an accredited medical assisting course with this application).
*Training in a secondary; post secondary or adult education program in a public school authorized by the Department of Education; in a community college program; post-secondary institution approved by the Bureau of Private Post Secondary and Vocational Education or Department of Consumer Affairs.
At least two years employment within the last five years as a medical assistant in the United States:
Employer Name: __________________________________________Phone:________________________
Address: ____________________________________________Job Title: ___________________________
(Attach verification from previous employer or at least two years of tax forms (W-2’s) as proof AND a PHYSICIAN signed injection/venipuncture proficiency statement).
Current employment as a Medical Assisting Instructor in an accredited institution in the United States:
School Name: ______________________________________________Phone:_______________________
(Attach employment verification).
OR United States Military training: Served in the capacity of a medical assistant while enlisted: and either separated from the Military within the last year or served in that capacity for at least two of the previous five years. 1) A copy of your DD214 will be required 2) An injection/venipuncture proficiency statement signed by your Commanding Officer is also required for clients taking the Clinical exam.
***FAILURE TO INCLUDE NECESSARY DOCUMENTATION WITH INITIAL APPLICATION WILL
DELAY THE APPLICATION PROCESS. ***
SCHOOL GRADUATE: Training to perform venipunctures and/or injections as required in Section 1366.1 of California Medical Assistant Regulations may be administered by a licensed physician or podiatrist, a registered nurse, licensed vocations nurse, or physician assistant. Training may also be administered by a qualified instructor in an accredited medical assisting program.
The supervising physician, podiatrist, nurse or instructor shall certify in writing the place and date such training was administered, the successful completion of each task, and shall sign the certification.
Medical assistants who are applying for CLINICAL certification are required to have:
Ten (10) clock hours of training in administering injections and performing skin tests and/or Ten (10) clock hours of training in venipuncture and skin puncture for the purpose of withdrawing blood, and Training shall include instruction and demonstration in pertinent anatomy and physiology appropriate to the procedures, choice of equipment, proper technique (including sterile technique), hazards and complications, patient care following treatment or test, emergency procedures, and California law and regulations for medical assistants.
Satisfactory performance by the trainee of at least ten (10) each of intramuscular, subcutaneous and intradermal injections, ten (10) skin tests and/or at least ten (10) venipunctures and ten (10) skin punctures.* I hereby certify that _____________________________________________________________has received training in injections and/or venipuncture as defined in the California Medical Assistant Regulations.
Location training was administered at: _________________________________________________________.
Date training was completed: _________________________. This candidate has successfully performed the minimum number of required injections/venipunctures (stated in the paragraph above*) A training log documenting these procedures will be maintained at my facility.
Print Instructor Name: _______________________________________________________________________
Instructor Signature: _________________________________________ Date: __________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EMPLOYED: If you are currently employed or have been employed as a medical assistant, you must provide a proficiency statement signed by your physician-employer.
I hereby certify that my current/previous (circle one) employee __________________________________is/was working within the Scope of Practice for a Medical Assistant and is proficient in administering injections and/or performing venipunctures.
________________________________________ ____________________________________ __________ Physician (Print Name) Physician’s Signature (MD, DO, DPM) Date ________________________________________ ______________________________________________
Official office stamp Phone ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CANCELLATION AND POSTPONEMENT POLICYFailing to appear for a scheduled test, arriving more than 15 minutes after the scheduled start time, refused admission to the exam, or changed the exam date without providing 24 hours’ notice will result in forfeiture of the entire fee. There will be no refund.
To reschedule the exam, do so by contacting Pearson Vue directly, our testing company, at the phone number found on the eligibility letter. You must test by the date that is specified in your eligibility letter.
If you wish to cancel your exam, you must do so in writing to CCBMA, not less than 15 days prior to your scheduled exam or the “must test by” date and contact Pearson Vue directly to have your appointment removed from the system. If you meet these deadlines, you will receive a refund of the application fee paid minus a $40 processing charge. Cancellation requests must meet these criteria or no refund will be given.
If your application is denied by CCBMA, you will receive a letter and a refund of your application fee minus a $40 processing charge.
SPECIAL ACCOMMODATIONSIndividuals requiring special provisions on examination day must request such exceptions in writing and it must be included with the initial application. Physical disability must be currently documented by a medical doctor. If you are requesting special accommodations because of a learning disability, documentation must be provided from a psychologist dated within the last year. The Certifying Board will make every effort to accommodate such cases, but it reserves the right to deny requests that, in the judgment of the Board, would jeopardize the security of the examination material or the integrity of scores derived from the examination.
RELEASE OF INFORMATIONI hereby give my permission for the Certifying Board to release my name, credential, email and mailing address to be used for educational and employment opportunities. No other information will be released without my knowledge and specific permission.
_____YES, I give permission to release my information. _____NO, I do not want my information released.
ACKNOWLEDGEMENTI acknowledge that I have read and understand the eligibility requirements, fees, cancellation/postponement, authorization of credit/debit card charges and refund policies, and that the information/documentation supplied in this application is true and accurate to the best of my knowledge.
PRINT your name as you want it to appear on your certificate:
(Please note that the name you registered under cannot be changed without documentation.) SUBMITTING YOUR APPLICATION: Please include all required supporting documentation and payment (Money order, cashier’s check, and VISA/MASTERCARD information). NO PERSONAL CHECKS ACCEPTED.
Please contact me at (____) ___________________for my credit card information OR my credit card information is attached on a separate sheet.
FAILURE TO INCLUDE NECESSARY DOCUMENTATION WITH THE INITIAL APPLICATION WILL CAUSE DELAYS IN PROCESSING
Name as it appears on the card:
Card Number: ________________________________________________________________
Expiration Date: ______________
3 digit security code (on back of card): ____________
Please charge the above card for $_____________
If cardholder is different from applicant, please indicate relationship:
Billing address for cardholder:
Shipping address (if different than billing address):
Telephone number: ____________________________________________________________