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
Important Information:
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):
For Office Use:
Nurse Practitioner Specialty and AANPCB Certification Number:
Adult NP
A -
Adult-Gero Primary Care NP
AG -
Emergency NP
E -
Family NP
F -
Gerontologic NP
G -
REQUESTING COMPANY INFORMATION
Company Name:
Credentialing Staff Contact Name:
Contact Email:
Company Address:
City State Zip:
Billing Information
Check here if Billing and Contact address are the same
Billing Address:
City State Zip:
Requesting Representative Information (The person we will contact in the event of billing or address delivery issues)
Name:
Email: Phone #:
Payment Information
Credit Card Type: Exp. Date:
Credit Card #: CVV #:
Name on Card:
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