STATE OF MARYLAND
APPLICATION FOR CERTIFICATION
TO PRACTICE AS A NURSE PSYCHOTHERAPIST
IN INDEPENDENT PRACTICE
INFORMATION SHEET
CRITERIA FOR CERTIFICATION
APPLICANTS APPLYING FOR CERTIFICATION TO INDEPENDENTLY PRACTICE AS A NURSE PSYCHOTHERAPIST IN MARYLAND MUST PROVIDE EVIDENCE OF:
1. CURRENT LICENSURE TO PRACTICE IN MARYLAND AS A REGISTERED NURSE.
APPLICANTS LIVING IN COMPACT STATES THAT HAVE IMPLEMENTED THE RN LICENSURE COMPACT: SUBMIT PROOF OF CURRENT REGISTERED NURSE LICENSURE ISSUED BY
THEIR LEGAL STATE OF RESIDENCE.
2. A MASTER’S DEGREE (OR HIGHER) IN PSYCHIATRIC MENTAL HEALTH NURSING.
3. CURRENT/ACTIVE CERTIFICATION ISSUED BY THE AMERICAN NURSES CREDENTIALING CENTER FOR CLINICAL SPECIALIST IN ADULT PSYCHIATRIC AND MENTAL HEALTH NURSING, OR CLINICAL SPECIALIST IN CHILD AND ADOLESCENT PSYCHIATRIC AND MENTAL HEALTH NURSING.
INSTRUCTIONS FOR THE APPLICANT
1. COMPLETE THE APPLICATION IN ITS ENTIRETY.2. SUBMIT THE (NON-REFUNDABLE) $50.00 PROCESSING FEE (CHECK OR MONEY ORDER MADE PAYABLE TO THE MARYLAND BOARD OF NURSING).
3. ATTACH A COPY OF YOUR CURRENT ANCC CERTIFICATION CERTIFICATE.
(CLINICAL SPECIALIST IN ADULT PSYCHIATRIC AND MENTAL HEALTH NURSING, OR CLINICAL SPECIALIST IN CHILD AND ADOLESCENT PSYCHIATRIC AND MENTAL HEALTH NURSING)
4. ATTACH A COPY OF YOUR MARYLAND** REGISTERED NURSE LICENSE.
**APPLICANTS LIVING IN COMPACT STATES-
ATTACH THE REGISTERED NURSE LICENSE ISSUED BY YOUR STATE OF LEGAL RESIDENCE.
5. ATTACH AN
OFFICIAL FINAL
TRANSCRIPT (MASTERS DEGREE OR HIGHER).ALLOW FOUR (4) WEEKS FOR PROCESSING
INCOMPLETE APPLICATIONS WILL REQUIRE ADDITIONAL PROCESSING TIME.
ONCE ISSUED, THE NEW CERTIFICATION MAY BE VIEWED AND PRINTED FROM THE BOARD’S WEBSITE WWW.MBON.ORG, “LOOK UP A LICENSEE”
MARYLAND BOARD OF NURSING
4140 PATTERSON AVENUE
BALTIMORE, MARYLAND 21215-2254
(410) 585-1900 (410) 358-3530 FAX
(410) 585-1978 AUTOMATED VERIFICATION
STATE OF MARYLAND
APPLICATION-PROCESSING FEES
THE NON-REFUNDABLE APPLICATION-PROCESSING FEE FOR THE INITIAL MARYLAND ADVANCED PRACTICE CERTIFICATION IS $50.00. THE NON-REFUNDABLE APPLICATION-PROCESSING FEE FOR THE SECOND AND THIRD ADVANCED PRACTICE CERTIFICATION IS $25.00.
NATIONAL CERTIFICATION BOARDS
AND
EXAMINATIONS ACCEPTED BY THE MARYLAND BOARD OF NURSING
THE MARYLAND BOARD OF NURSING CURRENTLY ACCEPTS THE FOLLOWING NATIONALCERTIFICATION EXAMINATIONS FOR NURSE PRACTITIONERS SPECIALTIES. CERTIFICATION FROM BOARDS OTHER THAN THE FOLLOWING WILL NOT CURRENTLY QUALIFY YOU FOR CERTIFICATION AS A NURSE PRACTITIONER IN MARYLAND.
NCC
NATIONAL CERTIFICATION CORPORATION
PNCB
PEDIATRIC NURSING CERTIFICATION BOARD
NEONATAL NURSE PRACTITIONER PEDIATRIC NURSE PRACTITIONER-PRIMARY CARE
OB/GYN NURSE PRACTITIONER ACUTE CARE NURSE PRACTITIONER
IF YOU HAVE QUESTIONS YOU MAY TELEPHONE THE BOARD AT (410) 585-1930 OR (410) 585-1926 ANCC
AMERICAN NURSES CREDENTIALING CENTER
AANP
AMERICAN ACADEMY OF NURSE PRACTITIONERS ACUTE CARE NURSE PRACTITIONER ADULT NURSE PRACTITIONER
ADULT NURSE PRACTITIONER FAMILY NURSE PRACTITIONER
CLINICAL SPECIALIST IN CHILD AND ADOLESCENT PSYCHIATRIC AND MENTAL HEALTH NURSING CLINICAL SPECIALIST IN ADULT PSYCHIATRIC AND MENTAL HEALTH NURSING
FAMILY NURSE PRACTITIONER
GERIATRIC NURSE PRACTITIONER
PEDIATRIC NURSE PRACTITIONER
PSYCHIATRIC MENTAL HEALTH-NURSE PRACTITIONER
SCHOOL NURSE
MARYLAND BOARD OF NURSING 4140 PATTERSON AVENUE BALTIMORE, MARYLAND 21215-2254 (410) 585-1900 (410) 358-3530 FAX (410) 585-1978 AUTOMATED VERIFICATION
STATE OF MARYLAND
PAGE 1 OF 4
NON-REFUNDABLE FEE: $50.00
APPLICATION FOR CERTIFICATION
TO PRACTICE AS A NURSE PSYCHOTHERAPIST
IN INDEPENDENT PRACTICE
I HEREBY MAKE APPLICATION FOR CERTIFICATION TO ENGAGE IN INDEPENDENT PRACTICE AS A NURSE
PSYCHOTHERAPIST IN THE STATE OF MARYLAND IN ACCORDANCE WITH THE MARYLAND ANNOTATED CODE, HEALTH OCCUPATIONS ARTICLE, 8-205 AND THE REGULATIONS GOVERNING NURSE PSYCHOTHERAPISTS IN INDEPENDENT PRACTICE (10.27.12) AND SUBMIT THE FOLLOWING EVIDENCE OF MY QUALIFICATIONS FOR CERTIFICATION.
NAME:
LAST FIRST MIDDLE/ MAIDEN
ADDRESS:
NUMBER AND STREET
CITY STATE ZIP CODE
**MARYLAND RN LICENSE #
ATTACH COPY OF LICENSE
**APPLICANTS
LIVING
IN COMPACT STATES, ATTACH COPYOF THE RN LICENSE ISSUED BY YOUR STATE OF LEGAL RESIDENCE
DATE OF BIRTH HOME
TELEPHONE
SOCIAL SECURITY #
E-MAIL ADDRESS:
MARYLAND BOARD OF NURSING
4140 PATTERSON AVENUE
BALTIMORE, MARYLAND 21215-2254
(410) 585-1900 (410) 358-3530 FAX
(410) 585-1978 AUTOMATED VERIFICATION
PAGE 2 OF 4
PRACTICE LOCATIONS
(ATTACH AN ADDITIONAL SHEET, IF MORE SPACE IS NEEDED)
NAME OF PRACTICE:
ADDRESS:
NUMBER AND STREET
CITY STATE ZIP CODE
TELEPHONE #
GRADUATE/POST GRADUATE EDUCATION
NAME OF SCHOOL: ADDRESS: NAME OF PROGRAM/TRACK: TYPE OF DEGREE/CERTIFICATE CONFERRED YEAR OF GRADUATION OR COMPLETION DATE
PAGE 3 OF 4
NATIONAL CERTIFICATION
HAVE YOU PASSED THE ANCC CLINICAL SPECIALIST IN CHILD AND ADOLESCENT PSYCHIATRIC AND MENTAL HEALTH NURSING NATIONAL CERTIFICATION EXAMINATION OR THE ANCC CLINICAL SPECIALIST IN ADULT PSYCHIATRIC AND MENTAL HEALTH NURSING NATIONAL CERTIFICATION
EXAMINATION?
YES NO
PENDING
IF YES, WHAT WAS THE NAME OF THE EXAMINATION
AREA OF SPECIALIZATION DATE CERTIFICATION CONFERRED CERTIFICATION EXPIRATION DATE
ATTACH A COPY OF YOUR ANCC CERTIFICATION CERTIFICATE
PRINT THE NAME YOU WOULD LIKE TO APPEAR ON YOUR CERTIFICATE:
I VERIFY THAT ALL INFORMATION CONTAINED IN THIS FORM IS TRUE AND COMPLETE.
SIGNATURE DATE
MAIL TO:
ADVANCE PRACTICE UNIT, MARYLAND BOARD OF NURSING, 4140 PATTERSON AVENUE, BALTIMORE, MD 21215-2254
07/2005
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MARYLAND BOARD OF NURSING 4140 PATTERSON AVENUE BALTIMORE, MARYLAND 21215-2254
(410) 585-1900 (410) 358-3530 FAX (410) 585-1978 AUTOMATED VERIFICATION
