MHIMA Program Director Verification - RHIA/RHIT Reimbursement

1. About the Applicant

First Name *This question is required.

Last Name *This question is required.

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

Program *This question is required.

Graduation Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. About the Program Director

First Name *This question is required.

Last Name *This question is required.

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

3. About the School

Name of School *This question is required.

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

4. Please upload a brief letter of reference for the above named student. Be sure your assessment of this student reflects his or her potential for professional leadership.

File: {{filename}} delete

5. I verify that the above listed applicant graduated from the Health Information Administration (RHIA) or Health Information Technology (RHIT) program specified above. *This question is required.

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