MICN Re-Authorization Application

MICN Re-Authorization Application
SS# *
MICN # *
Authorization expiration: *

Month Day Year
Currently Expired: *

Yes No
Name *

Last First MI (N/A if not applicable) Suffix
Home Address *

Street Address

Street Address Line 2

City State

Zip Code
This is my mailing address *

Yes No
Mailing Address

Street Address

Street Address Line 2

City State

Zip Code
I would like my card(s): *

Mailed - Card will be mailed to address on application Pick Up - You will be notified via email when ready
Per Instructions: Please allow 5-7 business days for processing
Best Contact Number *
Alternate Number
Driver's License # *
DOB *

Month Day Year
RN License # *
Expiration: *

Month Day Year
Age Range: *
Gender: *
Race/Ethnicity: *
Email *

Confirmation Email
Primary EMS Employer: *
Other Employer
YOU MUST ANSWER THIS QUESTION OR APPLICATION WILL BE REJECTED
Have you ever had any action taken against your nursing license? *

Yes No
Have you ever had any action taken against your MICN authorization? *

Yes No
If yes, attach an explanation that describes the action, any corrective action, and/or remediation as a result of the action.
Upload Supporting Documents *

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I hereby certify under penalty of perjury that I am not precluded from authorization for those reasons defined in section 1798.200 of the Health and Safety Code, which are as follows:

1. Fraud in the procurement of any certification under this division.

2. Gross negligence.

3. Repeated negligent acts.

4. Incompetence.

5. The commission of any fraudulent, dishonest or corrupt act that is substantially related to the qualifications, functions and duties of prehospital personnel.

6. Conviction of any crime which is substantially related to the qualifications, function and duties of prehospital personnel. The record of conviction or a certified copy of the record shall be conclusive evidence of the conviction.

7. Violating or attempting to violate directly or indirectly or assisting in abetting the violation of, or conspiring to violate any provision of this division or the regulations promulgated by the authority pertaining to the prehospital personnel.

8. Violating or attempting to violate any federal or state statute or regulation which regulates narcotics, dangerous drugs or controlled substances.

9. Addiction to, the excessive use of, or the misuse of alcoholic beverages, narcotics, dangerous drugs or controlled substances.

10. Functioning outside the supervision of medical control in the field care system operating at the local level, except as authorized by any other license or certification.

11. Demonstration of irrational behavior or occurence of a physical disability to the extent that a resonable and prudent person would have reasonable cause to believe that the ability to perform the duties normally expected may be impaired.

I have read and understand Section 1798.200 of the Health and Safety code (above). I am not precluded from being authorized for any reason defined in Section 1798.200 or I have enclosed a complete explanation of any item that applies to me.
I have read and understand the above statements, please initial: *
Required Documents
REQUIRED DOCUMENTATION (if not expired): *

Driver's License 16 hours CE certificates Copy of RN printout (BreEZe) 4 - MCI module certificates Passport style photo/Selfie
Upload Required Documents:

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See Requirements - Please attach all items separately 1 MB limit per attachment Cancel of
Additional documents may be sent via email to Certifications@mvemsa.com, please use last name in subject line.
Applications missing required documentation/information will be delayed
Payment Information
Re-Authorization Fee $50 ~ ~ ~ Late Fee (if applicable) $15
Debit or Credit (CHECK ALL THAT APPLY)
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MICN Re-Authorization $ 50.00

Late Fee (EXPIRED ONLY) $ 15.00
NO PAYMENT REQUIRED

YOUR EMPLOYER WILL BE INVOICED FOR CERTIFICATION FEES ONLY
ALL LATE FEES ARE THE RESPONSIBILITY OF APPLICANT
PLEASE NOTE: APPLICATION WILL NOT BE PROCESSED UNTIL PAYMENT IS RECEIVED
Print Name: *
Signature *

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MICN Re-Authorization Application

Required Documents

Payment Information