AQH Renewal: Maintenance of Certification – National Headache Foundation

To complete your AQH Renewal application, please be prepared to upload a copy of your current medical license and documentation of at least 50 CME units (or 75 hours within the past 60 months) related to headache medicine from the past three years.

After signing and submitting the form, you will be automatically directed to a secure site to pay the $250.00 renewal fee.

All submitted materials will be reviewed by the AQH Science Committee. Once your application is approved, your updated certificate will be emailed to you.

If you have any questions, please contact us at [email protected].

Name

First

Last

Certifications, (such as MD, NP, etc.), as you wish it to appear on your examination records and certificate:

Phone

Phone type

Personal email

Mailing address

Address Line 1

Address Line 2

City

State

Zip Code

(Optional) Social media links

Business name

Business email

Business address

Address Line 1

Address Line 2

City

State

Zip Code

Business phone number

Business website/URL

Preferred communications

Specialty (if applicable)

(Optional) Social media links

Full, unrestricted medical license

State issuing license:

License number:

Do you carry Malpractice Insurance

Have you ever been convicted of a felony?

I am a licensed healthcare provider with prescriptive authority, independently evaluating and managing headache patients.

Copy of current medical license

Click or drag a file to this area to upload.

Copy of CME: Minimum 50 units in headache medicine from the last three years (or 75 hours within the past 60 months)

Click or drag files to this area to upload. You can upload up to 25 files.

I certify that the information submitted in this application and the documents enclosed are correct to the best of my knowledge and belief. I understand that, if the information I have submitted is found to be incomplete or inaccurate, my application may be rejected or my examination results may be delayed or voided, not released, or invalidated by the National Headache Foundation.

I acknowledge that I have read all terms of the application and examination process and agree with all terms as stated.

Name

First

Last

Full, Copy headache

Signature

Clear Signature

Date / Time

Date

Time

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Once you click Submit, your completed application and all uploaded documents will be securely submitted to the National Headache Foundation for AQH renewal review.

You will then be automatically redirected to our secure payment portal to complete the final step of the process.