Association for Clinical Documentation Improvement Specialists

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*: required fields

1. Personal information

* Full Name

Name: *

Suffix:

Address

Your certificate will be mailed to the following address.
Your home address will not be used for marketing or commercial purposes.

Home address: *

Location

City: *

State: *

Zip *

Country*

Phone

Home

Cell

*Company Name

Company Name *

*Company Address

Company Address *

Company Address 2

*City:

City: *

State: *

Zip: *

Country*

Work Phone:

Work Phone *

Work Fax:

*Company E-mail

E-mail:*

*ACDIS member

2. Educational background

*High School/GED

High School/GED *

Degree *

High School Location

City: *

State: *

Country*

College/University (last attended):

College or University (last attended):

Degree

City

State

Country

Additional college-level courses taken:

Additional college-level courses taken

3. Work experience

*Current facility/company name:

Facility/Company (Current) *

Dates of employment:

Dates of employment * to

*Immediate Supervisor

Supervisor Name *

Supervisor Phone *

E-mail address of supervisor: *

Supervisor E-mail address *

Facility/Company (Previous)

Dates of employment

Dates of employment to

5. Location of Exam

Please check where you plan to take the CCDS exam

Secure testing location

6. Release of examination results

ACDIS would like to recognize the achievement of all individuals who successfully complete the CCDS examination on the ACDIS Web site or in CDI Journal. May we use your name in these publications?

Yes

7. Americans with Disabilities Act

Will you require special accommodations for the administration of this examination?

Yes

(If yes, complete the 2-page Request for Special Examination Accommodations form and submit with this application.)

8. ACDIS Membership

1. Are you a member of the Association of Clinical Documentation Improvement Specialists (ACDIS)?

Yes

9. Code of ethics and signature

I hereby attest that the above information is true and accurate. I have read and fully understand the candidate handbook and all sections therein, as well as the ACDIS Code of Ethics. I agree to abide by the terms of the candidate handbook and the ACDIS Code of Ethics, as well as any other requirements set forth in this application.

I certify that I have fulfilled one of the four required routes to take the exam and that the information provided by me on thisapplication is accurate.

I understand that the submission of false information will be grounds for rejection of my application at the sole discretion of ACDIS. I understand that some applications may be audited for accuracy.

Accept Code of Ethics

Yes

**Please note: your application is not complete until you finish the checkout process**

Does your facility support your conference attendance?

Yes, it is paying for me and my team to attend.

Yes, it pays for CDI team members to attend on a rotating basis (one or more staff get to go each year).

Yes, it pays for the cost of the conference but does not reimburse us for room and board, travel costs.

Yes, but only in granting us paid time to attend. We pay for conference attendance and travel ourselves.

No, it only supports attendance for manager-level staff.

No, it has cut travel and training budgets due to the economy.

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JustCoding Virtual Summit: ICD-10-CM and ICD-10-PCS

The JustCoding Virtual Summit: ICD-10-CM and ICD-10-PCS brings together industry experts to help you and your organization meet the challenge of ICD-10 transition head on. Whether you are a coding professional or a supervisor, you'll leave this unique event with the confidence that you can manage the transition ahead.

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