Proctored Exam Certification Form

Please complete the entire form, then click the "Next" button. BLUE highlight areas indicate required fields.

PART 1: STUDENT INFORMATION
First Name
Last Name  
E-mail Address  
AHIMA Student ID Number Example: 1234567  
PART 2: PROCTOR INFORMATION
First Name
Last Name  
Relationship to Student
E-mail Address  
Daytime Phone Number  Example: 310-555-1212
Daytime Phone Extension
 
Company Name (if applicable)  
Street Address  
City  
State  
Zip Code
PART 3: SELECT THE FINAL EXAM YOU PROCTORED AND THE EXAM COMPLETION DATE
Abstracting Methods
Anatomy and Physiology
Basic CPT Coding—Part 1
Basic CPT Coding—Part 2
Basic ICD-9-CM Coding—Part 1
Basic ICD-9-CM Coding—Part 2
Cancer Disease Coding and Staging
Cancer Registry Operations
Cancer Registry Structure and Management
Computer Basics in Healthcare		 Follow-up, Data Quality and Utilization
Healthcare Data Content and Structure
Healthcare Delivery Systems
Medical Office Procedures
Medical Terminology
Oncology Treatment and Coding
Pathophysiology/Pharmacology
Professional Practice Experience
Reimbursement Methodology
Exam Completion Date
PART 4: PROCTOR CERTIFICATION STATEMENT

By submitting this Proctored Exam Certification Form, I hereby certify that the student identified in PART 1 of this form has taken and submitted for grading online under my supervision, the final exam for the course selected in PART 3 of this form. I further certify that the student identified in PART 1 of this form is not my spouse or otherwise related to me by blood or marriage.

Enter your initials if this certification statement is TRUE

Questions or Comments (optional)