AMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD Rev. 05.16.19
P.O. Box 12926 Austin, TX 78711-2826
Main (512) 637-0500 Toll-free (8550 822-6727 Fax (512) 637-0540
Email: Certification@aanpcert.org www.AANPCERT.org
VERIFICATION OF CERTIFICATION ORDER FORM
FOR CREDENTIALING SERVICE ORGANIZATIONS
DO NOT USE THIS FORM FOR STATE BOARD OF NURSING VERIFICATION
• AANPCB provides Primary Source Verification of Nurse Practitioner (NP) certification status.
• Verification requests must be accompanied by a signed release from the NP dated within 6 months of the request.
• Fee: $40 per Nurse Practitioner. Fee is due each time a different NP Specialty is requested.
• AANPCB will email Primary Source Verification Letters within 1 business day of receipt.
• This is a fillable PDF form. Download and save to your computer or print.
• Complete required information and submit form to AANPCB via email, fax, or mail.
• Questions about the Verification Process? Contact the Verification Dept. at (512) 637-0500, ext. 576.
INFORMATION REQUIRED FOR PROCESSING A VERIFICATION REQUEST (Please print clearly)
AANPCB NURSE PRACTITIONER INFORMATION
Name (First Middle Last):
Last 4 SSN: Month/date of birth (mm/dd):
Nurse Practitioner Specialty and AANPCB Certification Number:
Adult-Gero Primary Care NP
REQUESTING COMPANY INFORMATION
Credentialing Staff Contact Name:
City State Zip:
□ Check here if Billing and Contact address are the same
City State Zip:
Requesting Representative Information (The person we will contact in the event of billing or address delivery issues)
Email: Phone #:
Credit Card Type: Exp. Date:
Credit Card #: CVV #:
Name on Card: