Fillable Medical Assistant Program Application Packet (Austin Community College)

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Medical Assistant Program Application Packet (Austin Community College)

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Updated: Nov 2021 (AP)
Medical Assistant
Medical Assistant
Program Application Packet
Semester Requested (Check one): Fall Spring Summer Year:
Access to Austin Community College’s programs or activities shall not be limited on the basis of race, color, creed, national origin,
religion, age, gender, sexual orientation, political affiliation, or physical disability. Applications accepted year round.
Please Type or Clearly Print Date of Birth / _/
ACC Student ID: e-mail address:
Leave blank if you do not have one
ACC Email is the preferred method of communication
Name:
Last First Middle
Home Address:
Number & Street County City Zip
Day Phone: Alternate Phone:
State
Last 4 of SS #.
The following items are required for the Registered Medical Assistant Program:
Application Checklist:
3.
HIPAA Training Module at: http://sites.austincc.edu/hipaa/ (Initial and sign 3 pages of the
“HIPAA Confidentiality and Security Agreement Form” and sign Post-test completion form). All
4 sheets must be uploaded to CastleBranch, using code: UL43im.
4.
5.
6.
Complete and Sign this form (pages 1-2)
If you are under 22 years old, you must submit verification of meningitis vaccine. ( See latest
information on college website at:
http://www.austincc.edu/apply-and-register/
enrollment-steps/comply-with-meningitis-law/meningitis-compliance-steps
Schedule your orientation interview (512) 223-7055.
Bring this application and a copy of your GED, High School Diploma or College Transcript
to the orientation meeting. (Orientation Date: _____________________)
Medical Assistant
1.
2.
Create student account with CastleBranch by visiting: https://
mycb.castlebranch.com There is a $30.00 cost for this.
Immunization form completed, signed and dated by a licensed health
professional.
Use
Packet code
UL64im to upload immunization form.
____
____
____
____
____
____
For a list of program costs, course schedule and course requirements, please visit:
http://continue.austincc.edu/medical
If you have additional questions, please contact the CE Healthcare Advising Specialist, Aida
Lasanta, aida.lasanta@austincc.edu or 512-223-7118.
Medical Assistant
ADMINISTRATIVE
COURS
EWORK
:
•
HPRS 1006 Essentials of Medical Terminology (32 Contact hours)
•
MDCA 1009 Anatomy and Physiology (64 Contact hours)
•
MDCA 1002 Human Disease/ Pathophysiology (64 Contact hours)
•
HITT 1053 Legal and Ethical Aspects of Health Information (48 hours)
•
MDCA 1021 Administrative Procedures, CPR & First Aid Included (80 contact hours)
•
HITT 1049 Pharmacology (48 Contact hours)
•
MDCA 1017 Procedures in a Clinical Setting, EKG included (112 Contact hours)
•
MDCA 1076 Administration of Medication (32 hours)
•
MLAB 1001 Introduction to Clinical Lab Science (80 hours)
Complete (2)TWO-STEP TB SKIN TESTS, A CRIMINAL BACKGROUND CHECK,
INFLUENZA
PRACTICUM COURSWORK:
Before registering for your practicum, MDCA-1064 students must:
1.
2.
Updated: Nov 2021 AP
•
MDCA 1064 Practicum (160 contact hours)
CLINICAL COURSEWORK:
Before registering for your clinicals, MDCA-1076 and MLAB-1001 students
must:
Submit proof of health insurance coverage. See the following link for a short term
insurance quote if not currently insured: https://quote.hccmis.com/stm/Quote/Step1 Other
health insurance links include but are not limited to: https://www.healthcare.gov/ and http://
www.medicalaccessprogram.net/
IMPORTANT DRUG TEST NOTIFICATION EFFECTIVE 11-5-19:
A positive drug screen for marijuana metabolite is still considered a failed drug screen,
regardless of whether a student is using CBD (cannabidiol) products derived from hemp
plants that contain .3% or less delta 9 tetrahydrocannabinol (THC). (CBD products
derived from marijuana plants are not legal in the State of Texas.) If enough THC is
present, it will show up as a positive result on a urine drug screen. This means that using
CBD products may have the ability to cause a positive drug test. (updated 11-5-19)
Complete a 10-panel drug screen. Drug screens are only valid for 30 days.
Acceptance of an application does not guarantee a student a seat in the course. Classes may fill
quickly, preventing you from registering even though you have completed the application process.
Students must notify the Health Professions Institute, Continuing Education of any change in applicant
data. Failure to do so may result in the withdrawal of permission to register in the classes or the
inactivation of the application.
Updated: AUG 2021 (VDD) Medical Assistant
For
Continuing Education
Office Use Only
Track
: Day
________
Evening
________
Application Reviewed By:_______________________________ Date:
______________________
MDCA 1076 and MLAB 1001 petitioned by ___________________
Date:______________________
MDCA 1064 petitioned by _______________________________
Date:_______________________
I hereby certify that the information contained in this application is true and complete to the best of
my knowledge. I understand that any misrepresentation or falsification of information is cause for
denial of admission or expulsion from the College. I understand that the faculty and staff of the Health
Professions Institute, Continuing Education will read the information contained in this application.
I have read and understand all information included as part of this application.
___________________________________________________________ ___________________
Signature of Applicant Date
click to sign
signature
click to edit
Health Sciences
Health Professions (CE)
Immunizations and Tests
Required by State Law/Clinical Facilities
Name: ACC ID#:
Program: Date of Birth:
*Measles, Mumps, Rubella (MMR)/Varicella vaccines if not given on same day MUST be 28 days apart.
ALL DATES MUST INCLUDE MONTH, DAY AND YEAR.
Hepatitis B
A. Recombivax HB or Engerix-B Vaccine (initial dose)
A. Recombivax HB or Engerix-B Vaccine Dose 2 (minimum 4 weeks after
date #1)
A. Recombivax HB or Engerix-B Vaccine Dose 3 (minimum 8 weeks after
date #2 and minimum 16 weeks after date #1)
OR
Date #1:
Date #2:
Date #3:
B. Heplisav-B Vaccine (initial dose)
B. Heplisav-B Vaccine Dose 2 (minimum 4 weeks after date #1)
OR
Date #1:
Date #2:
C. Serologic test positive for Hepatitis B antibody
Date of Collection:
____Positive Result ____Negative Result
Tdap
A. Tdap—received after 6/10/05
B. Td—if Tdap is 10+ years old (must
list both dates)
Date (Tdap):
Date (Td):
Signature
Date
Revised 2/11/20
Measles (Rubeola)
, Mumps & Rubella
(MMR)
A. Two doses of Measles, Mumps, Rubella (MMR) vaccine on or after their first
birthday and at least 28 days apart
OR
Date #1:
Date #2:
B. Serologic test positive for Measles antibody
Date of Collection:
____Positive Result ____Negative Result
B. Serologic test positive for Mumps antibody
Date of Collection:
____Positive Result ____Negative Result
B. Serologic test positive for Rubella antibody
Date of Collection:
____Positive Result ____Negative Result
Varicella
A. Two doses of Varicella vaccine on or after their first birthday and at least 28
days apart.
OR
Date #1:
Date #2:
B. Serologic test positive for Varicella antibody
OR
Date of Collection:
____Positive Result ____Negative Result
C. Physician documented history of Varicella (Chicken Pox)
Disease Date:
Order Instructions for
1. Go to https://mycb.castlebranch.com/
2. In the upper right hand corner, enter the Package Code that is below.
Package Code UL43im: Phase 1
About CastleBranch
Austin Community College - CE Medical Assistant and CastleBranch – one of the top ten
background screening and compliance management companies in the nation – have
partnered to make your onboarding process as easy as possible. Here, you will begin the
process of establishing an account and starting your order. Along the way, you will find
more detailed instructions on how to complete the specific information requested by your
organization. Once the requirements have been fulfilled, the results will be submitted on
your behalf.
Payment Information
Your payment options include Visa, Mastercard, Discover, Debit, electronic check and
money orders. Note: Use of electronic check or money order will delay order processing
until payment is received.
Accessing Your Account
To access your account, log in using the email address you provided and the password you
created during order placement. Your administrator will have their own secure portal to view
your compliance status and results.
Contact Us
For additional assistance, please contact the Service Desk at 888-723-4263 or visit
https://mycb.castlebranch.com/help for further information.
Austin Community College - Health Sciences
https://portal.castlebranch.com/UL29/spif/UL43/UL43im
1 of 1
7/19/2016 11:50 AM
Order Instructions for
1. Go to https://mycb.castlebranch.com/
2. In the upper right hand corner, enter the Package Code that is below.
Package Code UL64im: Core Requirements for Applicants
About CastleBranch
Austin Community College - AA Immunizations and CastleBranch – one of the top ten
background screening and compliance management companies in the nation – have
partnered to make your onboarding process as easy as possible. Here, you will begin the
process of establishing an account and starting your order. Along the way, you will find
more detailed instructions on how to complete the specific information requested by your
organization. Once the requirements have been fulfilled, the results will be submitted on
your behalf.
Payment Information
Your payment options include Visa, Mastercard, Discover, Debit, electronic check and
money orders. Note: Use of electronic check or money order will delay order processing
until payment is received.
Accessing Your Account
To access your account, log in using the email address you provided and the password you
created during order placement. Your administrator will have their own secure portal to view
your compliance status and results.
Contact Us
For additional assistance, please contact the Service Desk at 888-723-4263 or visit
https://mycb.castlebranch.com/help for further information.
Austin Community College - Health Sciences https://portal.castlebranch.com/UL29/spif/UL64/UL64im
1 of 1
7/19/2016 11:38 AM
CastleBranch.com • phone: 888.7
23.4263
1
Submitting Documents
Submitting documents to myCB can be achieved three ways: via upload, fax, or mail. This guide will cover all three
options. If you need any further assistance, please call the number located at the bottom right of every page.
UPLOADING DOCUMENTS
The most ecient way to submit. Uploading your documents through myCB is not only secure, but ensures faster
processing time.
Options for Digitizing Your Document
Take a picture
Use the myCB app
Scan your document
Utilize a local FedEx, UPS, Library, or University’s resources
Submitting Through myCB
Click To-Do Lists within the myCB panel on the left
Expand the requirement you wish to upload to
Click Browse next to Your Computer or Flash Drive
Select file(s) needed, one at a time
Hit Submit
Note: Document removal may only happen before submission. Make sure you have attached the correct file
name(s) before submitting. To remove a document, simply click Remove Document and re-attach the correct
version.
All Documents uploaded are stored in
your Document Center for future use.
To attach a previously uploaded
document to a requirement, follow
the same steps and then click Browse
next to My Documents.
Replacing Rejected Documents
Read the rejected reason
Re-upload using the same steps above
The two most common rejection reasons are missing information and illegible documentation. Make sure your
documents are easily legible and contain their essential information, such as: signatures, physical exam dates,
vaccination dates, or titer collection dates.
CastleBranch.com • phone: 888.7
23.4263
2
Submitting Documents
FAXING DIRECTLY TO REQUIREMENTS
Following the steps below will result in your documents automatically attaching to their specific requirements,
designated by their included cover letters.
Print Cover Letters
Click To-Do Lists within the myCB panel on the left
Expand the requirement you wish to upload to
Click Download at the bottom
Read and close the warning prompt
Print the cover letter
Follow the directions on the cover sheet
Repeat for all requirements to be faxed
FAXING TO DOCUMENT CENTER
Following the steps below will result in your documents going into your myCB document center, where you will
need to attach them to each requirement individually.
Print Cover Letter
Click Document Center within the myCB panel on the left
Click Print/Fax Mail Cover Sheet on far right
Read and close the warning prompt
Print the cover sheet
Follow the directions on the cover sheet
Faxed documents will display under My Documents within the Faxed folder
Submit Through myCB
Click To-Do Lists within the myCB panel on the left
Expand the requirement you wish to upload to
Click Browse next to My Documents
Choose the Faxed folder
Pick document needed
Hit Submit
CastleBranch.com • phone: 888.7
23.4263
3
Submitting Documents
MERGING FAXED PAGES
If submitting more than one document to a requirement, you have the option to merge them together.
To Merge Pages
Click Document Center
Find the Faxed/Mailed Documents folder
Select one file you wish to merge with another
Click Add PDF to Merge Queue
Repeat until all pages you wish to merge are queued
Select Merge These Documents at the top right
All merged files can be found in the Merged Files folder.
MAILING DOCUMENTS TO CASTLEBRANCH
Follow the steps below to mail documents to CastleBranch for review.
Print Cover Letters
Click T
o-Do Lists within the myCB panel on the left
Expand the requirement you wish to mail in
Click Download at the bottom
Read and close the warning prompt
Print the cover letter
Repeat for all requirements to be sent in
Mail to:
CastleBranch
1844 Sir Tyler Drive
Wilmington, NC 28405
Attn: TDL Document Center
Note: Pages mailed to CastleBranch should
be ordered accordingly:
Cover letter A, document A
Cover letter B, document B
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Medical Assistant Program Application Packet (Austin Community College)

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Completed 15 April 2022

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