: NAMSS ISP Enrollment Agreement

NAMSS ISP Enrollment Agreement

To enroll in the Independent Study Program, complete all fields of the NAMSS ISP Enrollment Agreement. This form may be printed and mailed to NAMSS with the supporting documentation and appropriate fees or it may be submitted online using a credit card. Do not submit this form online if you are paying by check. Complete and print the form, then send it with your payment.

Proof of education: a copy of your high school transcript or diploma, GED certificate or higher should be forwarded to the Executive Office within 30 days of completing the Enrollment Agreement. Failure to complete the requirements of the Enrollment Agreement will block you from continuing your studies. Mail your proof of education to:

Attention: NAMSS Education Department
2025 M Street NW, Suite 800
Washington, DC 20036

Read the NAMSS ISP Enrollment Agreement completely before agreeing to the terms and conditions.

If you are a currently enrolled student, do not complete this Enrollment Agreement again. Instead, log onto the secured site and complete the Enrollment Agreement for current students.

ISP Enrollment Agreement / Course Order Form

NAMSS Contact Information:
NAMSS Executive Office
2025 M St. , NW
Suite 800
Washington , DC 20036
Ph: 202-367-1196
Fax: 202-367-2196

Are you currently a
member of NAMSS:

Yes

If No, please click here and complete the NAMSS Membership application before proceeding.

Last Name:

First Name:

Title:

Miss Mrs Ms Mr

Home Address:

City:

State:

Zip:

Your name as it appears on
transcript / high school
diploma / or GED certificate:

Birth Date (MM/DD/YYYY):

Home Phone (with area code):

Work Phone (with area code):

Work Fax (with area code):

Email:

VERIFICATION OF EDUCATIONAL EXPERIENCE

Enrollment in the NAMSS Independent Study Program (ISP) requires an official transcript, diploma, or GED certificate as evidence of high school completion. Please complete the following fields:

My transcript/diploma/certificate has been request from the following institution: and is being sent directly to the NAMSS Institute. The date of my request was:

The NAMSS ISP is not meant to serve as a student's single source of information necessary to pass the certification exam, but rather to enhance skills related to a given course. If your reason for enrolling in the program is to sit for CPMSM or CPCS certification, please refer to the current eligibility criteria, which can be found on the NAMSS web site at www.namss.org.

Reason For Enrolling:

Please read the following Terms & Conditions:

I understand and agree to the Terms & Conditions: Agree Disagree

MARK APPROPRIATE BOX

Five Course Program (Discounted for ordering all five courses at once) $1,050

Course 1 - Administration and Management

$250.00

Course 2 - Medical Terminology

$250.00

Course 3 - Principles of Medical Staff Organization and Healthcare Finance

$250.00

Course 4 - An Overview of Accreditation Knowledge

$250.00

Course 5 - An Overview of Healthcare Law

$250.00

Course 6 - An Overview of Managed Care

$250.00

Coming Soon

Total Tuition:

One time ISP Enrollment Fee:

$50.00

TOTAL DUE:

PAYMENT OPTIONS

Please bill to the following credit card:

Visa Master Card AMEX Discover

Name (as it appears on card):
Account Number:
Expiration Date:

If you wish to pay by check, please print this form using the Print button on the right. Checks should be made payable to 'NAMSS' and mailed to:

NAMSS

Washington, DC

2025 M Street NW, Suite 800

Washington, DC 20036 USA

Phone: 202-367-1196

Fax: 202-367-2196