Fillable Initial & Renewal Provider Status Application (Pennsylvania Certification Board)

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Initial & Renewal Provider Status Application (Pennsylvania Certification Board)

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The Initial & Renewal Provider Status Application (Pennsylvania Certification Board) form is 3 pages long and contains:

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  • 14 check-boxes
  • 21 other fields

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File type: PDF

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PCB | Education Approval Application for Provider Status | Revised September 2019 1
298 S. Progress Avenue, Harrisburg, PA 17109
Phone: 717-540-4455 Fax: 717-540-4458
www.pacertboard.org info@pacertboard.org
EDUCATION APPROVAL
APPLICATION
PROVIDER STATUS: INITIAL & RENEWAL
PCB | Education Approval Application for Provider Status | Revised September 2019 2
PROVIDER STATUS INFORMATION
PCB has established Provider Status for organizations who wish to obtain PCB approval for educational
trainings they offer or sponsor.
BENEFITS OF BEING AN APPROVED EDUCATION PROVIDER
• Assured of offering training that professionals must acquire for recertification
• Organization can market trainings as PCB Approved
• Approved education is listed on the PCB website which is the first place professionals seeking
recertification are directed for education.
o The website is searchable by organization, topic, region, credential, online or in person
training and date.
• Approved education is searchable by credential and if it fulfills ethics hours on the website so
professionals can easily find hours they need for recertification and initial applications.
REQUIREMENTS FOR THE ORGANIZATION
1. Education eligible for PCB approval must be relevant to the field of behavioral health or community
health.
2. Education must use a formal structure.
3. Education must occur in Pennsylvania unless the organization is an online education provider.
4. Each training must be submitted using the Education Approval Form. Note: there are two Education
Approval Forms depending on the type of training you are submitting – in person or online.
PROVIDER STATUS AGREEMENT TERMS & CONDITIONS
1. The agreement period is one-year.
2. Trainings cannot carryover into another year if they are not used.
3. A predetermined, non-refundable fee is set by PCB for review of trainings. The fee is paid at the
beginning of the agreement.
4. Upon review and approval of the agreement, the organization will receive an assigned PCB Provider
Status number which will be used and referred to throughout the one-year agreement period.
5. The organization must establish one contact person who will correspond with PCB. This will be the
only person whom PCB will provide information to regarding training approval and is the only person
who should submit training approval applications to PCB.
6. Prior to the end of the agreement year, information on renewing your Provider Status will be sent to
the contact person.
TO SUBMIT YOUR APPLICATION, CHOOSE ONE OF THE FOLLOWING:
• EMAIL: education@pacertboard.org NOTE: Only PDFs are acceptable. PCB does not accept photos of
applications.
• FAX: 717-540-4458
• MAIL: PCB: 298 S. Progress Avenue | Harrisburg, PA 17109
To confirm receipt of your application, or check on the status, you must email education@pacertboard.org.
PCB | Education Approval Application for Provider Status | Revised September 2019 3
PROVIDER STATUS APPLICATION
Form can be completed and saved. You may then print the appropriate pages to submit to PCB.
TYPE OR PRINT LEGIBLY
CHECK ONE: □ Initial Application □ Renewal Application - Provider Status Number: ________________
Name:
Email:
Website:
I agree to adhere to PCB’s requirements, terms and conditions for Provider Status. Failure to do so could result in
cancellation of Provider Status with PCB or the denial of education hours submitted for PCB approval. This agreement is
effective for one-year from date of processing and receipt of payment. I understand the contact person above is the only
person who is to submit education approval to PCB.
Signature:
Date:
Select the category for the number of trainings your organization will submit for PCB approval. If you need additional
trainings approved, the cost is $75/training until the end of the agreement year.
NUMBER OF TRAININGS
FEE
☐
1-5
$300
☐
6-10
$400
☐
11-15
$500
☐
16-20
$600
☐
College/University
$600
☐
21 & Above
$700
PAYMENT INFORMATION: FEE MUST ACCOMPANY APPLICATION
PAYMENT (CHECK ONE): □ Check □ Money Order □ VISA □ MasterCard □ Discover □ American Express
Checks & Money Orders made payable to PCB
Email address for receipt (credit card only): _______________________________________________________________
TO SUBMIT YOUR APPLICATION, CHOOSE ONE OF THE FOLLOWING:
• EMAIL: education@pacertboard.org NOTE: Only PDFs are acceptable. PCB does not accept photos of applications.
• FAX: 717-540-4458
• MAIL: PCB: 298 S. Progress Avenue | Harrisburg, PA 17109
Address:
City:
State:
Zip:
Contact Person:
Email:
Number:
-
-
-
Sec. Code:
Exp. Date:
Name on Card:
Billing address:
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Initial & Renewal Provider Status Application (Pennsylvania Certification Board)

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Completed 3 June 2021

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