Cbhcm-P Upgrade

CBHCM-P UPGRADE Application

REQUIREMENT People holding the CBHCM-P credential must complete the work experience requirement and apply for an upgrade to the CBHCM credential at least 30 calendar days before the provisional credential expires. CBHCM-P applicants must:  Be employed by an Agency for Health Care Administration (AHCA) enrolled mental health targeted case management provider.  Meet all FCB administrative requirements and the CBHCM-P Upgrade specific standards and eligibility requirements. Please see the CBHCM-P Standards Table for details.  Provide the Certified Behavioral Health Case Manager – Provisional Status UPGRADE Work Verification Form to their employer for completion and submission to the FCB. This form must be received by the FCB at least 30 calendar days before the provisional credential expires.

APPLICATION FOR CBHCM-P UPGRADE  Prepare and submit the CBHCM-P UPGRADE Application. The CBHCM-P UPGRADE application is only available in hard-copy at this time. There is NOT an electronic application for the CBHCM-P UPGRADE.  This form is for all applicants with a valid CBHCM-P credential who are seeking full certification.  This form is to be completed by the applicant.  All information must be TYPED. Handwritten forms will be denied.  The work experience requirement must be completed during the provisional period and employer-provided Work Verification documentation must be received at least 30 calendar days before the provisional certification expiration date.  The first time the CBHCM credential is issued it will be valid for slightly less than or slightly more than 12 months, depending on the date the credential is issued. Credentials issued for the first time in the months of January, February or March will renew the following March 31st. After the first renewal, the credential will be issued for a 2-year period, always expiring on March 31st of the renewal year.  This application and the $50 certification fee can be sent via mail, email or fax. US Mail: FCB  1715 South Gadsden Street  Tallahassee, FL 321301 Email : Applications are assigned to Certification Specialists based on the applicant’s current employer. Please see the CBHCM-CBHCMS Certification Specialist Assignment document posted online at http://flcertificationboard.org/certification/case-management-credentials/ for the correct email address. FAX : 850-222-6247

Florida Certification Board (FCB) CBHCM-P UPGRADE Application Effective Date: 12-19-17 CBHCM-P UPGRADE Application

All information must be typed. Handwritten forms will be denied.

Part 1: Applicant Information. Provide requested information EXACTLY as it is entered in your FCB online account. Applicant Name: Primary Email Address: Current Employer: Credential Name: CBHCM-P Credential #: Issuing Florida Authority: Certification Board Issue Date: Expiration Date:

Part 2: Assurance and Release By my signature below, I attest that:

1. I am applyi ng to the Florid a Certifi cation Board (FCB) for an upgra de from CBHC M-P to CBHC M certifi cation . 2. I have receiv ed, read and Florida Certification Board (FCB) CBHCM-P UPGRADE Application Effective Date: 12-19-17 CBHCM-P UPGRADE Application under stand the curren t Candi date Guide: Applic ation for Certifi cation and the relate d standa rds tables and agree to abide by all terms and condit ions therei n. 3. I under stand that certifi cation award is contin gent upon my succes sfully meeti ng all applic able FCB Florida Certification Board (FCB) CBHCM-P UPGRADE Application Effective Date: 12-19-17 CBHCM-P UPGRADE Application policie s and crede ntial- specifi c certifi cation standa rds and requir ement s. 4. I under stand that false or mislea ding state ments or omissi on of inform ation may result in the denial or revoca tion of certifi cation . 5. I give my permi ssion to the FCB and its staff to investi gate Florida Certification Board (FCB) CBHCM-P UPGRADE Application Effective Date: 12-19-17 CBHCM-P UPGRADE Application my backgr ound as it relate s to inform ation contai ned in my applic ation for certifi cation . 6. I conse nt to the releas e of inform ation contai ned in my applic ation, certifi cation record (s) and/o r any other pertin ent inform ation to FCB staff and memb ers of the FCB Board of Florida Certification Board (FCB) CBHCM-P UPGRADE Application Effective Date: 12-19-17 CBHCM-P UPGRADE Application Direct ors and its Adviso ry Board s, Counc ils and review comm ittees. 7. I under stand the FCB will publis h my name, crede ntial inform ation and any histor y of ethical misco nduct/ discipl inary action in respo nse to public search es made throug h the FCB online crede ntial verific ation Florida Certification Board (FCB) CBHCM-P UPGRADE Application Effective Date: 12-19-17 CBHCM-P UPGRADE Application syste m. 8. I agree to hold the FCB, its staff, memb ers of the FCB Board of Direct ors and memb ers of FCB Adviso ry Board s, Counc ils and review comm ittees free from any civil liabilit y for damag es resulti ng for any action s that is within the scope of the perfor Florida Certification Board (FCB) CBHCM-P UPGRADE Application Effective Date: 12-19-17 CBHCM-P UPGRADE Application mance of their duties which is taken in conne ction with the review of this applic ation for certifi cation , subse quent exami nation s, allegat ions of ethical misco nduct, discipl inary proce edings and imple menta tion of FCB policy which may result in denial or revoca tion of certifi cation

Florida Certification Board (FCB) CBHCM-P UPGRADE Application Effective Date: 12-19-17 CBHCM-P UPGRADE Application for cause. 9. I under stand that FCB certifi cation relate d fees are non- refund able, even if it is deter mined that I am not eligibl e for certifi cation for any reaso n. 10. I hereb y affirm that the inform ation provid ed in this applic ation is correc t and that I believ e that I am Florida Certification Board (FCB) CBHCM-P UPGRADE Application Effective Date: 12-19-17 CBHCM-P UPGRADE Application qualifi ed for the level of certifi cation for which I am applyi ng.

Signature (FCB Date accepts both manual and electronic signatures) For FCB Use Only

Florida Certification Board (FCB) CBHCM-P UPGRADE Application Effective Date: 12-19-17