Externship Application

* Required Fields

Date:

Name*:

Applicant Address*:

City*:

State*:

Telephone Number*:

Email*:

Institution/Program of Attendance*:

City*:

State*:

Current GPA*:

Projected Graduation Date*:

Projected Externship Start Date*:

Highest Level of Education*: High School Diploma Some College Graduate Degree Graduate Degree Other

If Other, Please Specify:

Do you have any previous experience in the medical field?*
Yes - or - No

If Yes, how many years?

Do you have any previous experience with medical billing or coding?*
Yes - or - No

If Yes, how many years?

Which program are you interested in?*
Program 1: 200 hour, hands-on, in office apprentice program. Completion of this program will provide a letter of recommendation outlining the skills received to obtain an entry level position of employment in Medical Billing

Program 2: 960 hour, hands-on, in office apprentice program. Completion of this program will provide a letter of recommendation outlining the skills received to obtain an entry level position of employment in Medical Billing as well as knowledge to test with the NCCT (https://www.ncctinc.com/Certifications/INS.aspx) for national certification, testing fee and materials paid by FMBS.

Please list any other volunteer/intern/extern experience you have:

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