Approved Provider Intent to Apply/Eligibility Verification

Organizations interested in submitting an application for approval or renewal of approval as an Approved Provider must complete the Eligibility Verification and meet all Eligibility Requirements. Verification forms received from organizations that do not meet Eligibility Requirements will be rejected without substantive review.

Name of Organization*

Street Address of Organization*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you currently a VNA Approved Provider Unit?*

YesNo

Please enter your Approved Provider #:*

Identify your organization type: (To identify your organization type, please review the definitions found on our webpage: http://www.virginianurses.com/Main-Menu-Category/Education/Become-an-Approved-Provider/Provider-Application-Fees.html)*

Primary Point of Contact:*

First NameLast Name

Point of Contact Credentials: (enter none if none)*

Point of Contact Job Title/Position:*

Point of Contact Phone Number:*

Area CodePhone Number

Point of Contact Email Address:*

example@example.com

A Primary Nurse Planner is utilized as the contact for the ANCC Accredited Approver Unit and ensures compliance with the ANCC accreditation criteria.*

YesNo

Primary Nurse Planner's Name:*

First NameLast Name

Primary Nurse Planner's Credentials: (Please include all educational degrees)*

Primary Nurse Planner's RN License Number:*

Primary Nurse Planner's State of Licensure:*

Please list the names and credentials of all current Nurse Planners: (If the Primary Nurse Planner is the only Nurse Planner, please state this.)*

All Nurse Planners are currently licensed registered nurses with baccalaureate degrees or higher in nursing.*

YesNo

A Nurse Planner listed above is an active participant in the planning, implementing and evaluation process of each continuing education activity.*

YesNo

During the past year, did the applicant organization promote/market/advertise the majority (51% or more) of its learning activities to nurses within a single Health and Human Services (HHS) region and its contiguous states? (For region information, refer to https://www.hhs.gov/about/agencies/iea/regional-offices/index.html)? For example: An Approved Provider Organization in the state of Virginia would be required to target the majority of its activities within Region 3, which includes Virginia, Delaware, Maryland, Pennsylvania, West Virginia, District of Columbia, and its contiguous states.*

YesNo

Please proceed to section 4.

The applicant organization is not eligible for Approved Provider status, but may be eligible to be an Individual Activity Applicant or for Accredited Provider status. Please contact the VNA Program Director.

The applicant organization must answer the following questions and provide any additional required information.

The applicant has been operational for 6 months using the ANCC Accreditation Criteria.*

YesNoNot yet, but will be at application time

List the date the organization became operational:*

Date

The applicant organization is not eligible for Approved Provider status.

The applicant has assessed, planned, implemented, and evaluated at least three separate educational activities, within the past 12 months, provided at separate and distinct events, at least 1 hour in length, with the direct involvement of the Nurse Planner, and that adhere to the ANCC Educational Design Criteria. Contact hours may or may not have been offered.*

YesNoRenewing applicant with less than three activities in the past year

Applicant organization is in compliance with all applicable Federal, State, and Local laws and regulations that apply to the delivery of CNE.*

YesNo

The following section is intended to collect information about the applicant organization’s corporate structure. Ineligible companies are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Some organization types are automatically exempt from ANCC’s definition of an ineligible company, including:

Constituent Member Associations of the American Nurses Association

Specialty Nursing Organizations

Ambulatory procedure centers
Blood banks
Diagnostic labs that do not sell proprietary products
Electronic health records companies
Government or military agencies

Federal Nursing Services
Group medical practices
Health law firms
Health profession membership organizations
Hospitals or healthcare delivery systems
Infusion centers
Insurance or managed care companies
Nursing homes
Pharmacies that do not manufacture proprietary compounds
Publishing or education companies
Rehabilitation centers
Schools of nursing, medicine, or health science universities
Software or game developers

A single-focused organization* devoted to offering nursing continuing professional development

*A single focused organization exists for the single purpose of providing NCPD.

NOTE: 501c organizations are not automatically exempt. The ANCC Accreditation Program requires 501c organizations to be screened for eligibility.

Selecting "exempt" below identifies the applicant organization as exempt from ANCC’s definition of an ineligible company.*

ExemptNot exempt

Please continue onto Section 6.

Identify the applicant organization's exemption type from section 2 above and enter it here:*

You have completed this questionnaire and should proceed to Section 8.

According to your answer above, the applicant organization is not exempt from the ANCC Accreditation Program’s definition of an ineligible company. The following questions must be answered, so Virginia Nurses Association can assess the applicant organization's eligibility.

Note: Companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare goods or services used by or on patients are ineligible for ANCC accreditation per the Standards for Integrity and Independence in Accredited Continuing Education.

Does the applicant organization produce, market, sell, re-sell, or distribute healthcare products use by or on patients?*

YesNo

The applicant organization is not eligible for Approved Provider status.

Does your organization: (1) Advocate for an ineligible company; (2) Have a non-primary business function that includes producing, marketing, selling, reselling, or distributing healthcare products used by or on patients and/or advocating for or on behalf of an ineligible company; (3) Have a parent company that produces, markets, sells, re-sells, or distributes healthcare products used by or on patients and/or advocates for, or on behalf, of an ineligible company; (4)Have a sister company that produces, markets, sells, re-sells, or distributes healthcare products used by or on patients and/or advocates for, or on behalf, of an ineligible company*

YesNo

You have completed this questionnaire and should proceed to Section 8.

Is the applicant organization a separate and distinct entity from the MFO*?*

YesNo

Continue to Section 7.

The applicant organization is not eligible for Approved Provider status.

Does the multi-focused organization that owns the applicant organization have a 501-C Non-profit Status?*

YesNo

Does the company that owns your organization advocate for an ineligible company (as defined by the ANCC Accreditation Program)?*

YesNoNot sure

Please describe the relationship the company that owns your organization has with an ineligible company and the types of work the company that owns your organization does for or on behalf of an ineligible company that might be considered advocacy. *

Is any component of the multi-focused organization an entity that produces, markets, re-sells, or distributes healthcare products used by or on patients?*

YesNo

Please describe the healthcare products use by or on patients and the role of the entity in producing, marketing, re-selling or distributing those healthcare products.*

You have completed this questionnaire, proceed to Section 8.

Please download and fill out the Approved Provider Eligibility Commercial Interest Addendum and attach below to be submitted with this Form. Right click the link to open the link in a new tab so you do not lose your work.

Attach Approved Provider Eligibility Commercial Interest Addendum here.*

Upload a File

Accounting Department Contact Information*

First NameLast Name

Accounting Department Email Address*

example@example.com

Accounting Department Phone Number*

Area CodePhone Number

I attest that I understand it is my responsibility to contact the accounting department to determine what is needed for timely payment of Approved Provider invoicing. Specific payment details must be sent to ahenry@virginianurses.com. Approved Provider Invoice will be sent six months prior to due date.

Approved Provider Invoicing Information Attestation*

I attest, by my signature below, that I am duly authorized by the organization outlined in this application to submit this application as an approved provider offered by the American Nurses Credentialing Center (ANCC) through Accredited Approvers and to make the statements herein. On behalf of the organization outlined in this application, I have read the approved provider eligibility requirements and criteria. I understand that the organization outlined in this application is subject to all eligibility requirements and criteria as an approved provider. I understand that becoming an approved provider depends on successfully meeting eligibility requirements and criteria and maintaining approved provider standing is dependent upon continued compliance.

On behalf of the organization outlined in this application, I expressly acknowledge and agree that information accumulated through the approval process may be used for statistical, research, and evaluation purposes and that anonymous and aggregate data may be released to third parties. Otherwise, all information will be kept confidential and shall not be used for any other purposes without the organization outlined in this application’s permission.

On behalf of the organization outlined in this application, I hereby certify that the information provided on and with this application is true, complete, and correct. I further attest, by my signature on behalf of the organization outlined in this application, that the organization outlined in this application will comply with all eligibility requirements and approval criteria throughout the entire approval period, including all reapplication periods for maintaining approval, and that the organization outlined in this application will notify the Virginia Nurses Association promptly if, for any reason while this application is pending or during any approval period, the organization outlined in this application does not maintain compliance. I understand that any misstatement of material fact submitted on, with or in furtherance of this application for approved provider status shall be sufficient cause for the Virginia Nurses Association to deny, suspend or terminate the approved provider status of the organization outlined in this application and to take other appropriate action against the organization outlined in this application.

The box below serves as the electronic signature of the individual completing this form and attests to the accuracy of the information contained.*

Completed by:

First NameLast Name

Title:

Date*

Date

Approved Provider Intent to Apply/Eligibility Verification

Section 1: Demographic Data

Section 2: Nurse Planners

Section 3: Regional Target Market

Section 4:

Section 5: Eligibility

Section 6 - Only complete this section if applicant organization is not exempt

Section 7

Section 8: Invoicing Information

Section 9: Statement of Understanding