MEDICAL CODING ACADEMY
STUDENT APPLICATION
P.O. Box 120325, East Haven, CT 06512
Telephone: (203) 848-0496 Email: medicalcodingac@aol.com
Date: __________________ Name: __________________________________________________________
Last First Middle
Address: ________________________________________________________
Street City State Zip
Home Telephone: ___________________________
Work Telephone: ___________________________
Cellular Telephone: __________________________
In Case of Emergency, Notify:
Name ____________________________________
Relationship: _________________________
Address ________________________________________________Telephone Number___________________
Payment Source: Self _________ Employer _________
CPC or CPC-H class (please circle one)
Payment Method: Check # _______ Cash ______ MC/VS # ______________________
**Tuition fee includes a non-refundable $100.00 registration fee **Please circle appropriate credit card type
The MEDICAL CODING ACADEMY does not discriminate in acceptance into the curriculum, or on any other decision, on the basis of race, color, sex, martial status, citizenship and national origin, ancestry or on the basis of age or physical or mental disability unrelated to ability to perform the functions of a Certified Professional Coder. No question on this application is intended to secure information to be used for such discrimination. Applicants must be at least eighteen years of age. Please note if you have been convicted of a felony or other criminal history it may be a barrier to healthcare employment. Medical Coding Academy currently does not have a placement program and will not guarantee placement after successful completion.
Student Signature: _____________________________________ Date: ___________
PLEAS EFORWARD YOUR COMPLETED APPLICATION AND TUITION PAYMENT TO:
MEDICAL CODING ACADEMY
P.O. Box 120325, East Haven, CT 06512
ATTN: SECRETARY
(203) 848-0496
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