RUG Training Replacement Certificate Request Form

An individual Certificate Request Form must be submitted for each person.

Choose the Course you completed: *

RUG for MDS - Medicaid Fraud For Nursing Facilities

RUG for MN/LOC - Medicaid Fraud for Community Services

Are you wanting a replacement certificate for your current RUG training or from a previous year? *

Current Training Period

Previous Training Period

If this request is for a previous training period, please provide the year it was completed.

Last Name: *

First Name *

Email to send the certificate to: *

Repeat / Confirm E-mail address: *

Nursing License Number (6 characters are required) *

Repeat/Confirm Nursing License Number *

State that issued your license *

Your Position (R.N., L.V.N., etc.) *

Phone number where you can be contacted 8-5, M-F (include area code) *

If you happen to see this, do not fill this field.