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The Prometric CNA Renewal form is a crucial document for individuals seeking to renew their nursing assistant certification in Michigan. Completion of this form requires accurate information, including personal details such as your Social Security number, name, date of birth, and current address. It is necessary to provide the details of your employment, including the name and address of your employer, along with relevant dates of hire and termination if applicable. Specific eligibility criteria must be met to ensure successful renewal; candidates must have worked for pay as a nursing assistant for at least eight hours within the last 24 months. Additionally, any changes to your legal name need to be supported by official documentation. This helps avoid delays or denial of your application. All relevant sections must be filled out completely, as missing, blurry, or illegible information may result in processing issues. Once the form is completed, it must be mailed to Prometric, along with the required payment, which can be made by credit card or money order. The renewal process includes an affirmation of the accuracy of the information provided, underscoring the importance of honesty in the application. Further assistance and details can be accessed on the Prometric website.

Prometric Cna Renewal Example

* R E N E W A L C N A M I *

Michigan Nursing Assistant

Registry Renewal Form

Instructions:

Please go to www.prometric.com/NurseAide/MI to print the current version of this application and all other forms. DO NOT submit photocopies as this may impact the ability to process the application. Incomplete, blurred or illegible forms will not be processed.

Please complete all of the information requested on this form, including the employer information on Page 2 of this form. Failure to fully complete all pages may result in delays or denial of the renewal of your certification.

Please mail completed original forms to Prometric, ATTN: MI Nurse Aide Registry Renewal, 7941

Corporate Drive, Nottingham, MD 21236.

If your legal name has changed since last communication with Prometric, you must provide a copy of acceptable legal documentation along with this application. Acceptable documents include marriage certificate; divorce decree; birth certificate; and legal name change court documents. Prometric will be unable to process your application until the legal acceptable documents are received.

Eligibility for Renewal

You are eligible to renew your certificate if you have worked as a nursing assistant performing nursing or nursing- related services to a patient or resident for pay for at least eight consecutive hours within the immediate 24-month period prior to your current registry document expiration date. Nursing assistants with employment restrictions on the registry for resident abuse, neglect, misappropriation of resident property or criminal record disqualifications are not eligible for renewal.

Nursing Assistant Information

All fields marked with * are required. Print one number/letter in each box where required.

*Social Security Number --

*First Name

Middle Initial



*Last Name



*Date of Birth (Month/Day/Year)

//

Previous name (if applicable):

*Street Address (including Apt. number or P.O. Box, if applicable)

*City

*State  * ZIP Code 

*County (first four letters only)

 

Daytime Phone Number (including area code)

 

 

--

*Email Address (form will not be processed without an email address)

RENEWALCNAMI

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Rev. 01292019

Employment Information

Please complete the following section with your current or previous employer information.

*Name of Employer

*Address of Employer (Street Address or P.O. Box)

*City

 

*State

*Zip Code

 

 

Date of Hire: (MONTH/DAY/YEAR): ____________________________________

 

Are you currently employed at the facility listed above?

Yes

No

 

If No, Date of Termination: (MONTH/DAY/YEAR): ______________________________

 

 

 

 

 

Nursing Assistant Attestation and Signature

I certify that the information put forth on this Michigan Nursing Assistant Registry Renewal Form is true and correct to the best of my knowledge.

I understand that if I have given false information in this application, my nurse aide certification may be invalidated and I could be prosecuted by the state of Michigan.

Signature of Nursing Assistant (in box below)

Date: ______________________

Questions: For additional information, please visit our website at www.prometric.com/nurseaide.

Please make a copy of all completed forms for your personal records.

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Rev. 01292019

* P A Y C N A M I *

Payment Form

*Candidate Name: _____________________________________

*Date of Birth: ______________________

Credit Card Type (Check One)

 

 

 

MasterCard

Visa

American Express

 

 

 

 

 

 

 

Card Number

 

 

Expiration Date

 

 

 

 

/

 

Amount

 

 

C/C Security Code

$ __ __ __ . __ __



 

 

 

 

 

Name of Cardholder (Print)

Signature of Cardholder

Certified Check or Money Order Payments

Certified Check

3rd Party/Facility Check

Money Order

Certified Check/Money Order/3rd Party/Facility Check Number (one number or letter in each box):



Fee(s) may be paid by money order or certified check made payable to Prometric. Your name and ID (if available) must be written on the form of payment. Personal checks and cash are not accepted. Fees are non-refundable and non-

transferrable.

Please mail this completed form, any required documentation and $20 non-refundable processing renewal fee

in the form of a money order, certified check or American Express, Visa or Mastercard to:

Prometric

Attn: Michigan Nurse Aide Registry Renewal

7941 Corporate Drive

Nottingham, MD 21236

PAYCNAMI

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Rev. 01292019

Form Characteristics

Fact Name Details
Website for Forms Visit www.prometric.com/NurseAide/MI to print current application forms.
Submission Guidelines Do not submit photocopies of the form; they may result in processing delays.
Completion Requirement All information requested, including employer details, must be fully completed to avoid delays.
Address for Mailing Send completed forms to Prometric, ATTN: MI Nurse Aide Registry Renewal, 7941 Corporate Drive, Nottingham, MD 21236.
Legal Name Change Provide legal documentation if your name has changed; otherwise, your application cannot be processed.
Eligibility Criteria You must have worked as a nursing assistant for at least eight hours within the last 24 months to be eligible for renewal.
Disqualification Reasons Nursing assistants with registry restrictions related to abuse or criminal records cannot renew their certificates.
Required Information All fields marked with an asterisk (*) are compulsory for form submission.
Payment Process Fees can be paid via money order, certified check, or credit card. Personal checks and cash are not accepted.

Guidelines on Utilizing Prometric Cna Renewal

After gathering the required information and documentation, individuals can proceed to fill out the Prometric CNA Renewal form. It is important to ensure that every part of the form is fully completed before submission. Missing or unclear information can delay the processing of the application.

  1. Visit www.prometric.com/NurseAide/MI to print the current version of the application.
  2. Carefully read the instructions on the form.
  3. Fill in all *required fields, such as Social Security Number, First Name, Last Name, Date of Birth, and Contact Information.
  4. If your legal name has changed, include a copy of acceptable legal documentation, such as a marriage certificate or court documents.
  5. Complete the Employment Information section, listing your current or previous employer details.
  6. Indicate your employment status at the listed facility.
  7. Sign and date the Nursing Assistant Attestation and Signature section to certify the information provided is true.
  8. Prepare payment, either by credit card or certified check/money order.
  9. Mail the completed original form, along with any required documentation and payment, to:
    • Prometric
    • ATTN: MI Nurse Aide Registry Renewal
    • 7941 Corporate Drive
    • Nottingham, MD 21236
  10. Keep a copy of the completed form for your records.

What You Should Know About This Form

What is the purpose of the Prometric CNA Renewal Form?

This form is used to renew your certification as a Certified Nursing Assistant (CNA) in Michigan. It ensures that you continue to meet the requirements to perform nursing or nursing-related services. Renewal allows you to maintain your eligibility to work in this capacity by complying with state regulations and providing updated information regarding your employment history.

How do I obtain the most current version of the renewal form?

You can obtain the most current version of the Prometric CNA Renewal Form by visiting the website www.prometric.com/NurseAide/MI. It is essential to print the latest version and not submit photocopies, as doing so may impact your application processing. Incomplete, blurred, or illegible forms will not be processed.

What information is required on the renewal form?

The renewal form requires several critical details. You must fill in your Social Security Number, first name, last name, date of birth, contact information, and employer information. Each field marked with an asterisk (*) is mandatory. Make sure to provide accurate information, as inaccuracies can lead to delays or denial of your application.

What documents do I need to include if my name has changed?

If your legal name has changed since the last communication with Prometric, you need to include acceptable legal documentation with your application. Acceptable documents include a marriage certificate, divorce decree, birth certificate, or court documents showing the legal name change. Without this documentation, your application cannot be processed.

What are the eligibility requirements for renewing my CNA certification?

You are eligible to renew your CNA certification if you have worked for at least eight consecutive hours in a nursing or nursing-related capacity within the 24 months leading up to your certification's expiration date. Note that if there are any employment restrictions due to issues such as resident abuse or neglect, or if there are criminal record disqualifications, you will not be eligible for renewal.

How should I submit my completed renewal form?

Once you have completed the renewal form, mail the original version to Prometric at the following address: Prometric, ATTN: MI Nurse Aide Registry Renewal, 7941 Corporate Drive, Nottingham, MD 21236. Ensure you include any required documents and payment, as outlined in the instructions. Remember to keep a copy of all completed forms for your records.

Common mistakes

When filling out the Prometric CNA Renewal form, many applicants make common mistakes that can lead to delays or even denial of their renewal application. One major error is failing to provide required information. Certain fields are mandatory and must be filled out accurately. For instance, if the social security number or first name is missing, the application cannot be processed. Every section of the form must be completed, even if it seems minor.

Another frequent mistake involves the submission of photocopied forms. Applicants often overlook the instruction stating that only original forms should be sent. Photocopies may not be accepted, which could impact the overall processing time of the application. It’s essential to ensure that the correct, original version of the form is printed from the official website.

Incorrect information, particularly regarding previous names or employer details, is another common issue. Failure to update your legal name can create considerable confusion. If your name has changed, be sure to include legal documentation such as a marriage certificate or court order. Providing accurate and current employer information is equally important to avoid unnecessary back-and-forth and delays.

Many individuals also forget to attach their payment for the renewal fee. This oversight can result in the processing of the application being halted. Ensure that you check the payment method accepted and include the correct fee amount in the appropriate format, which could be in the form of a certified check or credit card information.

Inadequate attention to the legibility of the form is another area where mistakes often occur. Applications that are filled out in a rushed or sloppy manner may be deemed illegible and could be rejected. Printing clearly and using a black or blue pen can make a significant difference. Make sure every letter and number is clear and distinguishable.

Finally, some applicants neglect to sign and date the form. This may seem minor, but without a signature, the form is not valid. Take a moment to review the entire document before submission, ensuring that all signature boxes are filled out appropriately.

By avoiding these common mistakes, you can significantly enhance the likelihood of a smooth renewal process for your CNA certification. Pay attention to detail, provide all necessary information, and follow the guidelines precisely.

Documents used along the form

When renewing a nursing assistant certification with Prometric, several other forms and documents are typically required to ensure a smooth and efficient process. Understanding these supplementary documents can aid in timely and successful re-certification.

  • Payment Form: This form is essential for submitting renewal fees. It collects information regarding the payment method, including credit card details or information about checks. Accurate completion ensures processing of the payment alongside the renewal application.
  • Employer Verification Form: Some states require verification from your current or previous employer to confirm your employment duration as a nursing assistant. This validates the information you provide on your renewal application.
  • Legal Name Change Documentation: If there has been a change in your legal name since the last renewal, you must provide documentation proving the change. Acceptable documents include marriage certificates, divorce decrees, or court orders.
  • Continuing Education Certificates: Proof of any continuing education or in-service training completed since your last certification may also need to be submitted. This demonstrates your commitment to staying current in your field.
  • Criminal Background Check: In some cases, a recent criminal background check may be necessary, particularly if there have been issues since the last renewal. This document corroborates your eligibility for certification.
  • Application Checklist: A checklist often accompanies the renewal form to help applicants ensure they have included all required documents. This tool can prevent delays in processing due to missing information.

By familiarizing yourself with these additional documents and ensuring their proper completion, you can facilitate a more efficient renewal process for your nursing assistant certification. Always double-check each document for accuracy to avoid delays in your application.

Similar forms

  • State Certification Application: Similar to the Prometric CNA Renewal form, a State Certification Application requires personal information, confirmation of eligibility, and often the submission of training and employment history. Both documents aim to verify qualifications for a specific professional status.

  • Health Care Provider License Renewal Form: Much like the CNA renewal, this form necessitates the applicant’s current employment information and acknowledgment of adherence to professional standards. Both forms help maintain professional accountability and patient safety.

  • Professional License Application: The Professional License Application mirrors the CNA form in requesting personal and employment data to assess eligibility for professional practice. Both documents are essential in evaluating the qualifications of practitioners.

  • Background Check Consent Form: This form, necessary for many professional renewals, similarly collects personal information and requires the applicant's signature, ensuring legal compliance for practice in healthcare settings.

  • Continuing Education Certificate Submission: Like the CNA Renewal form, this document serves to confirm completion of required training for licensure renewal. Both emphasize the importance of ongoing education in maintaining professional competence.

  • Employment Verification Form: This document captures employment history similar to the CNA Renewal form. It requires details about previous and current employers, verifying work experience necessary for certification.

  • Name Change Notification Form: This form parallels the CNA application in its requirement for legal documentation when personal information changes, ensuring that official records remain accurate.

  • Application for Medical Assistance: This form shares a structure akin to that of the CNA Renewal form through its necessity for personal details and documentation verification to qualify for healthcare benefits.

  • Nursing License Endorsement Application: Similar in nature to the CNA Renewal, this application requires applicants to present verified work experience and professional information to transition their license from one state to another.

  • California Nurse Aide Registry Renewal Application: This application functions similarly to Prometric’s CNA Renewal, requiring proof of eligibility, personal information, and adherence to regulatory guidelines. Both forms help ensure that nursing assistants operate within the confines of the law.

Dos and Don'ts

Things You Should Do:

  • Visit www.prometric.com/NurseAide/MI to print the latest application and forms.
  • Complete all information requested on the application, ensuring no fields are left blank.
  • Mail the original signed forms to the specified address in Nottingham, MD.
  • Provide legal documentation if your name has changed since your last application.
  • Confirm you have worked as a nursing assistant for at least eight hours in the past 24 months.

Things You Shouldn't Do:

  • Do not send photocopies of the application, as they may not be processed.
  • Avoid submitting incomplete or unclear forms that could lead to delays.
  • Do not forget to include your email address, as it is required for processing.
  • Do not use personal checks or cash for payment; only certified checks, money orders, or credit cards are accepted.
  • Do not ignore employment restrictions that could disqualify you from renewal.

Misconceptions

  • Misconception 1: Photocopies of the renewal form are acceptable.
  • This is incorrect. You must submit the original form only. Photocopies may cause delays in processing your application.

  • Misconception 2: Only partial completion of the form is sufficient.
  • All fields marked with an asterisk are required. Failure to complete every section can lead to delays or denial of your renewal.

  • Misconception 3: You do not need to report a name change.
  • If your legal name has changed, you must include documentation like a marriage certificate or a court order along with your application.

  • Misconception 4: Payment can be made using a personal check.
  • This is not allowed. Only certified checks, money orders, or credit card payments are accepted. Personal checks and cash cannot be used.

Key takeaways

Filling out and submitting the Prometric CNA Renewal form is a vital step in maintaining your certification as a nursing assistant. Here are some key takeaways to ensure a smooth renewal process:

  • Use the Latest Version: Always obtain the most current version of the renewal application from the Prometric website. Submitting outdated forms or photocopies can lead to processing delays.
  • Complete Every Section: Ensure that all required information is filled out. Missing details or unclear handwriting may cause your application to be delayed or denied.
  • Provide Legal Name Documentation: If your name has changed, include acceptable legal documents like a marriage certificate or court order. This step is crucial for processing your application.
  • Eligibility Criteria: To qualify for renewal, you must have worked as a nursing assistant for at least eight consecutive hours within the last 24 months. Be aware that those with a history of abuse, neglect, or criminal disqualifications cannot renew.

By paying close attention to these aspects, you can streamline the renewal process and focus on what truly matters—providing quality care to your patients.