Medical Insurance Billing Cert Request

Medical Insurance Billing Certificate
Application Form

Please turn in application only if you have completed the program.

I have successfully completed the required courses for the Certificate in Medical Insurance Billing Certificate Award Program and am hereby entitled to receive the certificate.

Students: This certificate application is a record of your achievement. Like a grade report, it provides documentation for the certificate award. After you have completed all requirements, fill in this form and click the Submit Application button below.

Student Information

[Name as it should appear on the printed Certificate]

[Include Street Address, City, State and Zip Code]

Course Information

Required Course(s)Term Completed

Student Signature