MISSOURI NURSES ASSOCIATION
P.O. Box 105228 • Jefferson City, MO 65110
Voice: 573.636.4623 • Fax: 573.636.9576
www.missourinurses.org
APPROVED PROVIDER INTENT TO APPLY FORM
Organizations interested in submitting an application as an Approved Provider must complete the eligibility
verification process and meet all eligibility requirements and submit a $200 intent-to-apply fee1. The Missouri Nurses
Association is responsible for ensuring that the applicant is eligible to apply.
An Approved Provider is defined structurally and operationally as the members of the organization who support the
delivery of continuing nursing education activities. The Provider Unit may be a single-focused organization devoted to
offering continuing nursing education activities or a separately identified unit within a larger organization. If the
Provider Unit is within a larger organization it is defined as a multi-focused organization (MFO). The applicant
applying for approval is the Provider Unit (PU). The MFO organization is not the applicant.
Step 1 Contact Information
Name of Agency:
(Please type or print)
Address:
City/State/ZIP:
Contact Name:
Title:
Email:
Daytime Phone:
Fax:
Step 2 Eligibility Requirements
Please Note: To place an “X” in a shaded box below, double click the shaded box & select the “checked” option.
Have you previously been denied, suspended and/or had approval revoked from other ANCC Accredited
Approver Units and/or other accrediting/approving organization?
Yes
No
If yes, STOP and contact the MONA Office for guidance before moving forward.
Eligible applicants must: (NOTE – All boxes are required and must be checked)
Be one of the following: Constituent or State Nurses Association (C/SNA) of the American Nurses
Association (ANA), College or University, Healthcare facility, Health-related organization, Multidisciplinary educational group, Professional nursing education group, or an Specialty Nursing
Organization (SNO).
Be operational for a minimum of six (6) months prior to application.
Be in compliance with all applicable federal, state, and local laws and regulations that affect the
organization’s ability to meet the ANCC/MONA criteria.
Not be a commercial interest as defined in the Content Integrity Standards for Industry Support in
Continuing Nursing Educational Activities.
Market the majority (>50%) of their CNE activities to nurses in their local geographic region.
Agencies who target more than 50% of their CNE activities to nurses in multiple regions, or in states other
than those within or contiguous to a single region, are not eligible to become an Approved Provider and must
apply directly to the American Nurses Credentialing Center (ANCC) to become an Accredited Provider.
Activities offered via the Internet are considered to be targeted to nurses in multiple regions.
Be administratively and operationally responsible for coordinating the entire process of planning,
implementing, and delivering CNE.
Identify one Nurse Planner who will act as the Primary Nurse Planner and serve as the liaison
between the Missouri Nurses Association and the Approved Provider Unit.
Primary Nurse Planner Name & Credentials:
(If different from individual listed above)
Have a Primary Nurse Planner who holds a current, valid license as an RN and a baccalaureate
degree or higher in nursing.
Have a Primary Nurse Planner who has authority within the organization to ensure compliance with
the ANCC/MONA Accreditation criteria in the provision of CNE
Have a Primary Nurse Planner who is responsible for the orientation of all Nurse Planners and key
personnel in the organization to the ANCC/MONA Accreditation criteria.
Have completed the process of assessment, planning, implementation, and evaluation for at least 3
separate educational activities provided at separate and distinct events:
(a) with direct involvement of a Nurse Planner
(b) that adhered to the ANCC/MONA Accreditation criteria
(c) that were each a minimum of one hour (60 minutes) in length (contact hours may or may not
have been offered), and
(d) that were not co-provided
Step 3 Intent to Apply (please check one below)
YES – My organization plans to apply for provider approval with the Missouri Nurses Association
January cycle (Deadline November 1st of each calendar year) Year: ________
July cycle (Deadline May 1st of each calendar year) Year: _______
Four (4) copies of the Approved Provider Application and the appropriate review fee will be
submitted by the deadline listed above. (NOTE: Approved Provider applications received over 10 days
after the deadline will not be accepted for that cycle, without prior arrangements with the MONA Office. )
NO – My organization does NOT plan to apply for provider approval with the Missouri Nurses
Association.
If no, please share the reason for your decision:
Our agency will apply directly to the ANCC COA
The application fee is too costly
Our organization does not meet the eligibility requirements
Other – Please comment: _______________________________________________
Organization Representative:
Representative Title/Position:
Signature:
1
Date:
The intent-to-apply fee is non-refundable if the organization submits an intent-to-apply form and decides not to proceed with the
submission of the full Approved Provider application. The intent-to-apply fee will be credited toward the provider application review
fee for organizations that proceed forward with the full Provider Application.
OFFICE USE ONLY
Reviewed by:
Date:
Eligible:
Yes
No