"*" indicates required fields Step 1 of 7 - Renewal Application Overview 14% 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]. First Name*Last Name*Certifications, (such as MD, NP, etc.), as you wish it to appear on your examination records and certificate:*Phone*Phone type*Select OneMobileWorkOtherHomeMailing address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Social media links Business name*Business email* Business address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Business phone number*Business website/URL*Preferred communications*Select OneBusinessPersonalSpecialty (if applicable)Social media links Full, unrestricted medical license*Select OneYesNoState issuing medical license:*Select OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingMedical license number:*Do you carry Malpractice Insurance*Select OneYesNoHave you ever been convicted of a felony?*Select OneYesNoPlease explain:* I am a licensed healthcare provider with prescriptive authority, independently evaluating and managing headache patients.*Select OneYesNoProfessional title*Select OnePhysician (MD/DO)Physician AssistantNurse PractitionerOther with prescriptive authorityDo you have UCNS Certification*Select OneYesNoPlease describe your prescriptive authority:*Thank you for your interest in renewing your AQH certificate. Based on your response, you are not currently eligible to proceed with the AQH renewal application. If you believe this is an error or have questions about eligibility requirements, please contact us at [email protected]. Copy of current medical license*Max. file size: 512 MB. Copy of CME: Minimum 50 units in headache medicine from the last three years (or 75 hours within the past 60 months)*Max. file size: 512 MB. 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.First Name*Last Name*Signature*You may sign this field using your mouse, stylus, or finger on a touchscreen deviceDate* Time* Hours : Minutes AM PM AM/PM 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.
