AMERICAN HOSPITAL ASSOCIATION CERTIFICATION CENTER
CERTIFIED PROFESSIONAL IN HEALTHCARE RISK MANAGEMENT (CPHRM)
EXAMINATION APPLICATION PAGE 1 OF 2
Copyright 2014 by the AHA Certification Center (rev. June 2017)
To apply for the CPHRM Examination, complete this two-page application and return it with the examination fee to:
PSI, AHA-CC Examination, 18000 W. 105th St., Olathe, KS 66061-7543
FAX: 913-895-4651 PHONE: 888-519-9901
CANDIDATE INFORMATION
(First Name) (Middle Initial) (Last Name) Former name if exam was taken previously
List name as you wish to be printed on your certificate. under a different name.
Titles and designations will not be printed on the certificate.
Name of Facility/Company/Organization Title
Preferred Mailing Address (Street Address, City, State/Province, Zip/Postal Code, Country)
Preferred Telephone Number Email Address
EXAMINATION TYPE. Place a checkmark next to the type of exam administration for which you are applying. Select only one.
□
Computer administration at a PSI Test Center
□
Special domestic administration (For scheduled dates, see www.AHACertificationCenter.org.) Scheduled date and location:
□
International administration (For Request for International Examination Administration form, see www.AHACertificationCenter.org)
ELIGIBILITY REQUIREMENTS
To be eligible for the Certified Professional in Healthcare
Risk
Management (CPHRM) Examination, a candidate must
fulfill
one (1) of the following requirements for
education/healthcare
experience AND meet the
requirement for risk management
experience. By checking a
box below, a candidate certifies to
the AHA-CC that he or
she satisfies the eligibility requirement.
Check the one that
applies.
Education/Healthcare Experience
□
Baccalaureate degree or higher from an accredited college
or university plus five (5) years of experience in a
healthcare setting or with a provider of services to the
healthcare industry
□
Associate degree or equivalent from an accredited college
plus seven (7) years of experience in a healthcare setting
or with a provider of services to the healthcare industry.
□
High school diploma or equivalent plus nine (9) years of
experience in a healthcare setting or with a provider of
services to the healthcare industry.
Risk Management Experience
□
3,000 hours or 50 percent of full-time job duties within the
last three (3) years dedicated to healthcare risk
management in a healthcare setting or with a provider of
services (e.g. consultant, broker, attorney) to the
healthcare industry.
APPLICATION STATUS
Check one of the following.
□ I am applying as a new candidate.
□ I am applying as a re-applicant, i.e., retaking the exam.
□ I am applying for renewal of CPHRM certification.
MEMBERSHIP STATUS
If you are a current member of ASHRM or other AHA
Personal Membership Group (PMG), you are eligible for
the
reduced CPHRM Examination fee. Please provide
your 10-
digit membership number below.
For information on joining the American Society for
Healthcare Risk Management (ASHRM), visit
www.ASHRM.org. Membership must be obtained before
application for examination at the reduced fee can be
honored.
If you have applied for membership but have not yet
received your membership number, enter “NEW” below.
Membership Number:
CPHRM EXAMINATION FEES
Payment may be made by credit card, company check,
cashier’s check or money order made payable to PSI Services.
Indicate the type and amount of fees enclosed:
□ Member of ASHE or other AHA PMG………..…....$275
□ Nonmember:…………………………....…..…..…...$425
□ Rescheduling Fee…………………………………...$100
□ Member Voucher…………………………………….$0
** Note: If you are paying with a Member Voucher, the original voucher
is required. Copies will not be accepted.
For payment by credit card, complete the following.
Select type of credit card being used:
□VISA □MasterCard □American Express □Discover
Credit Card Number Expiration
Date
Your Name as it Appears on the Card
Signature