Application for Certification by: _____ Education _____ Reciprocity _____ Practice Experience


Name:____________________________________________________________________ Date :_____________

 Mailing Address:______________________________________________________________________________

City:____________________________________ State:_____________ Zip:____________________________

Phone:__________________________________ Fax:________________________________________________

Email Address:________________________________________________________________________________


School or Educational Program Attended for Case Management:______________________________________

Date of Completion:_________________________________ Number of hours of instruction:______________

Applicants must submit one of the following: 1) a copy of their certificate of completion, or 2) an official letter by the school, educational program, or instructor verifying successful completion of the program and the number of contact hours of the educational program. Note: if the certificate of completion does not have the number of contact hours detailed on it, then it is necessary to submit an official letter from the school, program or instructor verifying the number of hours or college credits earned.

For translation purposes, the AACM uses the following conversion: 50 minutes = 1 contact hour. 1 semester unit of college credit = 15 contact hours.


For Applicants applying for Reciprocity

Organization or Certifying Body you are currently certified by:_______________________________________

Date of certification:__________________________________ Date of expiration:________________________

Candidates must submit a copy of their current certification certificate or a copy of their official letter of certification by the organization or certifying body. The AACM reserves the right to contact such organization or body and verify certification of the applicant.


For applicants applying for Fellowship qualification by practice experience


If self employed, name of business:_______________________________________________________________

City:__________________________________ State:__________________ Zip:_________________________

Phone:______________________________________ Fax:____________________________________________

Number of hours of practice as a Case Manager within a four year period from this date of application:___________

Applicants must have two reference letters from current or former employer or private clients attesting to the fact that the Case Manager has practiced as a Case Manager in a healthcare role and the number of years of such practice. Reference letters must be sent directly to the office of the AACM. Applications will be considered pending until references are received. Applicants must also submit a copy of their current job description which details their practice role in case management.

Have references and job description sent to: American Academy of Case Management, 2400 Niles-Cortland Rd. S.E. Suite #4, Warren, Ohio 44484.


List all degrees/credentials earned to date:




Method of Payment

Application fee for 4 year term of Fellowship is $ 200.00

_____ Check

_____ Money Order

_____ Credit Card _____ Visa _____ MC


Card Number:____________________________________________________ Expiration:_________________

 Name on Card:___________________________________________________ Signature:___________________


I, the undersigned, verify that this application is complete, and to the best of my knowledge, all information provided is factual and true. I understand that failure to provided the needed information and required documentation could likely lead to delays in the processing of this application. I further understand that if any information supplied on this application is false, that I will be denied consideration for fellowship. I further understand that if at any time it is discovered that I have made false or untrue statements on this application, or misrepresented myself, or have provided fraudulent documentation to the AACM, that the AACM may rescind my fellowship status.



______________________________________________________________ Date:________________________