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INFORMATION SHEET MARYLAND CERTIFICATION TO PRACTICE AS A NURSE ANESTHETIST CRITERIA FOR MARYLAND NURSE ANESTHETIST CERTIFICATION

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STATE OF MARYLAND

INFORMATION SHEET

MARYLAND CERTIFICATION TO PRACTICE AS A NURSE ANESTHETIST

CRITERIA FOR MARYLAND NURSE ANESTHETIST CERTIFICATION

1 THE

$50.00

APPLICATION-PROCESSING FEE. (CHECK OR MONEY ORDER PAYABLE TO THE

MARYLAND BOARD OF NURSING)

2 COMPLETE THE APPLICATION IN ITS ENTIRETY.

3 CURRENT PERMANENT REGISTERED NURSE LICENSURE*.

A TEMPORARY REGISTERED NURSE LICENSE WILL NOT FULFILL THIS REQUIREMENT.

*APPLICANTS

LIVING

IN STATES THAT HAVE IMPLEMENTED THE RN LICENSURE COMPACT: SUBMIT PROOF OF ACTIVE/CURRENT REGISTERED NURSE LICENSURE ISSUED BY YOUR STATE OF LEGAL RESIDENCE.

4 AN OFFICIAL FINAL TRANSCRIPT – PROOF OF COMPLETION OF A MASTER’S DEGREE OR HIGHER. 5 A COPY OF THE CURRENT CERTIFICATION OR RECERTIFICATION CARD ISSUED BY THE COUNCIL ON

CERTIFICATION/RECERTIFICATION OF NURSE ANESTHETISTS.

6 YOU MAY NOT WORK IN MARYLAND AS A NURSE ANESTHETIST UNTIL YOU SUBMIT THE COLLABORATION AGREEMENT (PAGE 4 OF 5) FOR EACH WORKSITE OR FACILITY.

z THE COLLABORATOR’S MARYLAND MEDICAL LICENSE NUMBER, PRACTICE ADDRESS, AND THE ORIGINAL SIGNATURES OF THE NURSE ANESTHETISTS AND THE COLLABORATING ANESTHESIOLOGIST, PHYSICIAN OR DENTIST MUST APPEAR ON THE COLLABORATION

AGREEMENT

z SUBMIT A SEPARATE AGREEMENT FOR EACH COLLABORATOR OR FACILITY. 7. MAIL TO: ADVANCED PRACTICE UNIT, MARYLAND BOARD OF NURSING,

4140 PATTERSON AVENUE, BALTIMORE, MD 21215

8. ALLOW FOUR (4) WEEKS FOR PROCESSING. INCOMPLETE APPLICATIONS WILL REQUIRE ADDITIONAL PROCESSING TIME.

9. ONCE ISSUED, THE NEW CERTIFICATION MAY BE VIEWED AND PRINTED FROM THE BOARD’S WEBSITE WWW.MBON.ORG (LOOK-UP A LICENSEE).

QUESTIONS AND CONCERNS RELATING TO THE APPLICATION PROCESS SHOULD BE DIRECTED TO THE BOARD'S ADVANCED PRACTICE DEPARTMENT (410) 585-1926.

MARYLAND BOARD OF NURSING

4140 PATTERSON AVENUE

BALTIMORE, MARYLAND 21215-2254

(410) 585-1900 (410) 358-3530 FAX

(410) 585-1978 AUTOMATED VERIFICATION

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STATE OF MARYLAND

NON-REFUNDABLE FEE: $50.00

MARYLAND BOARD OF NURSING

APPLICATION FOR CERTIFICATION TO PRACTICE NURSE ANESTHESIA

I HEREBY MAKE APPLICATION FOR CERTIFICATION TO PRACTICE AS A NURSE ANESTHETIST IN THE STATE OF MARYLAND IN ACCORDANCE WITH THE MARYLAND ANNOTATED CODE, HEALTH

OCCUPATIONS ARTICLE, SECTION 8-205 AND THE REGULATIONS GOVERNING THE PRACTICE OF NURSE ANESTHETIST (10.27.06) AND SUBMIT THE FOLLOWING EVIDENCE OF MY QUALIFICATIONS FOR

CERTIFICATION.

DATE OF BIRTH

APPLICANTS RESIDING IN STATES THAT HAVE IMPLEMENTED THE RN LICENSURE COMPACT SUBMIT A

COPY OF YOUR

ACTIVE/PERMANENT REGISTERED NURSE LICENSE ISSUED BY YOUR STATE OF LEGAL RESIDENCE. MARYLAND

LICENSE #

…

PENDING

SOCIAL

SECURITY#

HOME TELEPHONE #

E-MAIL ADDRESS

PAGE 1 OF 5 NAME

LAST FIRST MIDDLE OR MAIDEN

ADDRESS

NUMBER AND STREET

CITY STATE ZIP CODE

MARYLAND BOARD OF NURSING

4140 PATTERSON AVENUE

BALTIMORE, MARYLAND 21215-2254

(410) 585-1900 (410) 358-3530 FAX

(410) 585-1978 AUTOMATED VERIFICATION

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PAGE 2 OF 5

WORK ADDRESS

NUMBER AND STREET

CITY STATE ZIP CODE

NAME OF FACILITY

OR PRACTICE WORK TELEPHONE #

NURSE ANESTHESIA PROGRAM

NAME OF SCHOOL

ADDRESS

NUMBER AND STREET

CITY STATE ZIP CODE

NAME OF PROGRAM

YEAR OF GRADUATION/ COMPLETION DATE

TYPE OF DEGREE OR CERTIFICATE CONFERRED

(4)

PAGE 3 OF 5

CERTIFICATION BY THE COUNCIL ON CERTIFICATION

OR RECERTIFICATION OF NURSE ANESTHETISTS

HAVE YOU TAKEN/SAT FOR THE

NATIONAL CERTIFICATION EXAM?

†

YES

†

NO

†

PENDING

(IF YES) DATE OF

INITIAL CERTIFICATION EXPIRATION DATE

z

ATTACH A COPY OF THE INITIAL CERTIFICATE

z

ATTACH A COPY OF THE CERTIFICATION/RECERTIFICATION CARD ISSUED BY THE COUNCIL ON CERTIFICATION/RECERTIFICATION OF NURSE ANESTHETISTS

z

DO

NOT

ATTACH COPIES OF MEMBERSHIP CARD

PRINT NAME DESIRED ON BOARD OF NURSING CERTIFICATE

I VERIFY THAT ALL INFORMATION CONTAINED IN THIS FORM IS TRUE AND COMPLETE.

ORIGINAL SIGNATURE DATE

MAIL TO:

ADVANCED PRACTICE UNIT, MARYLAND BOARD OF NURSING,

4140 PATTERSON AVENUE, BALTIMORE, MD 21215

REVISED 5/20/2004 REVISED 1/1/2006

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STATE OF MARYLAND

PAGE 4 OF 5

MARYLAND BOARD OF NURSING

NURSE ANESTHETIST AFFIRMATION OF COLLABORATION

(SUBMIT A SEPARATE AGREEMENT [WITH ORIGINAL SIGNATURES] FOR EACH COLLABORATOR OR FACILITY) DO NOT FAX

NAME OF NURSE ANESTHETIST:

(PRINT)

LAST

FIRST

MIDDLE

MARYLAND RN LICENSE NUMBER: ACTIVE COMPACT LICENSE NUMBER:

R

………………

AC

………………

NAME OF COLLABORATING ANESTHESIOLOGIST, PHYSICIAN OR DENTIST:

(PRINT) LAST

FIRST MIDDLE

MARYLAND MEDICAL LICENSE NUMBER OF THE COLLABORATING ANESTHESIOLOGIST, PHYSICIAN OR DENTIST:

D

…………………

H

…………………

DDS

…………………

COLLABORATOR’S PRIMARY FIELD OF PRACTICE OR SPECIALTY:

__________________________________

The undersigned applicant solemnly swears and affirms that the applicant is in full compliance

with Maryland regulations 10.27.06 including the requirement to collaborate with an

anesthesiologist, physician or dentist.

ORIGINAL SIGNATURE OF NURSE ANESTHETIST

DATE

Mail to: Advanced Practice Unit, Maryland Board of Nursing

4140 Patterson Avenue, Baltimore, MD 21215

APPROVED 12/1003, 8/28/2012

REVISED 5/2004, 1/2006, 10/2006, 10/2011, 8/2012

MARYLAND BOARD OF NURSING

4140 PATTERSON AVENUE

BALTIMORE, MARYLAND 21215-2254

(410) 585-1900 (410) 358-3530 FAX

(410) 585-1978 AUTOMATED VERIFICATION

(6)

STATE OF MARYLAND

PAGE 5 OF 5

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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

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