Missouri Credentialing Board

2018 Fall Renewal Attestation and Ethics


Attestation Statement - 

  


I, , attest I have completed all the necessary hours to renew my MCB credentials for the October 31, 2018 Renewal including all required “live” Ethics hours.
I understand that Missouri Credentialing Board (MCB) has the authority to request my certificates/documentation at any time and it is my responsibility to maintain my training certificates.

I understand that if my renewal is being audited, I must submit a copy of all my training certificates for review.  I further understand that even if I am not being audited, I still must submit a copy of my “live” ethics certificate in order to renew my credentials.  

 

AND

 

Renewal Certification Ethics -

  

I, , have read and will abide by the current MCB Treatment Ethics Code and/or the current MCB MRSS, CPS CRPR, BIP or Prevention Ethics Code listed on the website (www.missouricb.com) under the MCB Ethics Code Link.

AUTHORIZATION AND RELEASE

I, ,   hereby certify all of the information given herein is true and complete to the best of my knowledge and belief.  I also authorize any relevant investigations, or the release of personal information to the Missouri Credentialing Board, its agents, or contractors pursuant to this application/renewal procedure. 

I understand falsification of any portion of this application/renewal will result in my being denied credentialing, or revocation of same upon discovery.

I further agree to hold the Missouri Credentialing Board and its Board Members, officers, agents, staff, peer evaluators and examiners, free from any civil liability for damages or complaints by reason of any action that is within the scope and arise out of the performance of their duties which they, or any of them, may take in connection with this application/renewal, the examination, the grades with respect to any examination, and/or the failure of the MCB to issue me said credential or renewal.

This Authorization and Release shall also apply to personal information requested by the Board at any time following credentialing with connection with any investigation concerning allegations that could lead to disciplinary action against me.

 

 

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Missouri Credentialing Board https://missouricb.com
Signature Certificate
Document name: 2018 Fall Renewal Attestation and Ethics
lock iconUnique Document ID: 27de3766f3c2763b588865432ce44afdfd04b655
Timestamp Audit
September 7, 2018 1:36 pm CST2018 Fall Renewal Attestation and Ethics Uploaded by Stacey Langendoerfer - MOCredentialingBoard@gmail.com IP 173.22.130.239