Eligibility Form

Do you already have a Learner ID?

Please enter your Learner ID

First Name

Middle Name(s)

Last Name

Email

Country

Training Course

Did you complete High School?

Highest Level of Education Achieved

School / Institution Name

Have you previously received a certificate of completion for HIPAA Compliance Training?

Please provide the year completed

Upload HIPAA Certificate

Upload Proof of Education

Consent and Agreement

I confirm all information provided is true and correct to the best of my knowledge at time of submission.

I confirm that the submitter of the application is the same applicant.

I agree that if my application is selected for a random audit and any information is found to be incorrect or fraudulent at any time, the applicant forfeits all rights to the certificate received for completion of HIPAA training and no refund will be given.

I agree that if any information is found to be incorrect or false at any time during a random audit of this submission, the applicant forfeits all rights to the certificate received for the completion of HIPAA training and no refund will be given. The HIPAA Certificate will be revoked and the applicant will not be allowed to reapply for a new access code for the year in which the certificate was issued.

E-Signature

By typing your full name below, you agree that this serves as your electronic signature.

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