Verification -

Signature Date Name

Date / Time

Date

Time

Name

First

Last

Comment or Message

AFFIDAVIT OF CLINICAL EXPERIENCE Patient Care Technician (PCT) Experience Verification for Medical Assistant Certification Date: _______________________ I, ________________________________, affirm and attest that I have been employed and working as a Patient Care Technician (PCT) at Jackson Hospital since 2021. During my employment in this role, I have obtained hands-on clinical experience and routinely performed patient care tasks that are consistent with the duties and responsibilities commonly associated with the Medical Assistant (MA) profession. My clinical experience includes, but is not limited to, the following: ✔ Obtaining and documenting vital signs (blood pressure, pulse, respirations, temperature, oxygen saturation) ✔ Patient intake and preparation for examinations and procedures ✔ Electrocardiogram (EKG) procedures ✔ Specimen collection and phlebotomy support ✔ Assisting physicians and nurses with clinical procedures and patient care ✔ Medical documentation and charting ✔ Maintaining infection control and safety protocols ✔ Supporting patient monitoring and care activities ✔ Maintaining HIPAA compliance and patient confidentiality Through my employment and clinical experience since 2021, I have developed competencies and practical skills that align with the scope of practice and responsibilities of a Medical Assistant. I am submitting this affidavit in support of my Medical Assistant certification application to verify my prior clinical experience and healthcare skills. I certify that the information provided above is true, accurate, and complete to the best of my knowledge. Applicant Signature: Signature: _________________________________ Printed Name: ______________________________ Date: ____________________________________ Affirmation Checkbox for Online Form ☐ I affirm that the information provided in this affidavit is true and accurate.

Signature

Clear Signature