WYHIMA Exam Fee Reimbursement Application

Please complete the Exam Fee Reimbursement Application and submit with the requested documents.

If you have any questions please refer to the WYHIMA Exam Fee Reimbursement Program document on the WYHIMA webpage or send an inquiry to jlpoley@hotmail.com.

Personal Information

First Name *This question is required.

Last Name *This question is required.

Credentials

AHIMA ID Number *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.

Country *This question is required.

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

Phone Number *This question is required.

Fax Number

Mobile Phone

Education Information

College/University Name *This question is required.

Program Course *This question is required.

Date you passed the Certifying Exam *This question is required.

Required Documentation

Scan and upload the following documentation.

Written documentations showing your exam date and that the exam was successfully passed. (AHIMA Score Report) *This question is required.

File: {{filename}} delete

Acknowledgment

Signature *This question is required.

Clear

Signature of

Note: application must be received by WYHIMA within six (6) months after passing exam.

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

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