CCMI Exam Fee Payment – Breining Institute

You may submit a credit card payment for the Certified Case Manager Interventionist (CCMI) Examination Fee using this form.

You should only use this form if you have already completed and submitted the CCMI Application Packet

Do not use this form if you included the Exam Fee payment with your initial CCMI Application, and this is your first attempt at the CCMI Exam. You may use this form if this is your second or subsequent attempt to pass the CCMI Exam.

You will be automatically sent an email confirming this submission, to the email address that is included in this form, once you have selected the “Submit” button.

We will process this payment as soon as possible, typically within one business day.

Section 1: Candidate Information

Full Name: *

Email Address: *

Confirm Email Address: *

Primary Phone Number *

Section 2: CCMI Exam Payment Information

CCMI Exam Fee *

Non-refundable CCMI Exam fee of $175

Section 3: Optional / Additional Payment

If you are going to make a payment in addition to or different than one or more of those included in Section 2, above, please itemize and explain your payment here: *

Section 4: Credit Card and Payment Information

You give permission to and authorize Breining Institute to charge the total amount of the items selected in Section 3 and (if applicable) identified in Section 4, to the following credit card:

Credit Card: *

VISA

MasterCard

Discover

Credit Card Number: *

Full Name on Credit Card: *

Credit Card Expiration Date *