Before completing this form, please read the Candidate Bulletin of Information. Information is subject to verification. Please complete entire application. Incomplete applications will be returned.

Social Security Number:
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Home Street Address:

Home Telephone:
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Home E-mail Address:

Complete Name of Employer:

Office Street Address:

Office Telephone:
( ) - ext.

Office Fax:
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Office E-mail Address:

I hereby apply for recertification offered by the Radiology Coding Certification Board (RCCB) in accordance with and subject to its rules. I understand that the information gathered in the certification process will be used for statistical purposes and for evaluation of the certification program. I further understand that the RCCB will use its best efforts to keep all information related to this application and the certification process confidential.

To the best of my knowledge, the information contained in this application is true, complete and correct and is made in good faith. I understand that the RCCB reserves the right to verify any or all information on this application and that any incorrect or misleading information may constitute grounds for rejection of my application, revocation of my certification, or other disciplinary action.

I, the undersigned applicant, recognize and agree to the following. (If you agree, please check the box next to the item.)

I recognize that I must successfully complete the certification continuing education process before I can be considered certified and represent myself as such.

I recognize that, if certified, RCCB certification does not constitute RCCB endorsement, warranty or guaranty of my competency or fitness to practice in the radiology coding field.

I recognize that my credential will be Radiology Certified Coder (RCC) and that RCC and RCCB are registered logos and trademarks of the RCCB. I further agree to use such logos and trademarks only in accordance with RCCB policies.

I agree to inform the RCCB of changes or circumstances that may materially alter this application.

I agree that, if certified, my name may be included in the published list of RCCB certificants.

I agree to hold harmless RCCB for liability from verification/inspection of documents or records/investigations, from action taken during the certification process, and from failure to certify me as a Radiology Certified Coder.

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