Lifetime Achievement Route: Application Checklist

ABHRS APPLICATION

Lifetime Achievement Route
Please use this form as a tool to ensure that all needed information for your application is sent in. In order to submit this form, all checkboxes need to be completed.

Please click save at the bottom if you need to return later to complete the form. An email will be sent to you with a link to continue later.
Applicant Name:*
E-mail:*
Mobile:*
1.*

Signed Application
(Complete and Submit this Form: https://hipaa.jotform.com/222124314333441)
2.*

Copy of Government-Issued ID
*

Cancelof
3.*

Copy of M.D. or D.O. License
*

Cancelof
4.*

Affidavit of clear and unrestricted license(s)
(Complete and Submit this Form: https://hipaa.jotform.com/222123271887052)
5.*

Current and valid Life Support with External Defibrillator (“BLS/ED”) certification
*

Cancelof
6.*

Two Reference Letters from physicians who belong to ISHRS and/or ABHRS
*

Cancelof
7.*

Copy of Curriculum Vitae
*

Cancelof
8.*

Affidavit of role of hair restoration surgeon
(Complete and Submit this Form: https://hipaa.jotform.com/222095987325061)
9.*

AMA, AOA or FCVS Physician Profile Ordered by applicant from the AMA, AOA or FCVS (waived for physicians outside of US)
*

Cancelof
10.*

List of Hair Restoration meetings attended over the past three years
*

Cancelof
11.*

400 Case Logs for preceding eight years (4-5 per month for 96 months / 50 cases per year for 8 years) see example shown in this link https://abhrs.org/wp-content/uploads/2022/08/Case-Logs-updated-4.16.14.pdf
For example, if application is dated August 20, 2020 then case log will include cases from

August 2012 – July 2013 listing 50 cases   August 2016 – July 2017 listing 50 cases
August 2013 – July 2014 listing 50 cases   August 2017 – July 2018 listing 50 cases
August 2014 – July 2015 listing 50 cases   August 2018 – July 2019 listing 50 cases
August 2015 – July 2016 listing 50 cases   August 2019 – July 2020 listing 50 cases*
*

Cancelof
12.*

Operative Reports (50) see example shown in this link https://abhrs.org/wp-content/uploads/2022/08/Sample-Operative-Report.pdf
*

Cancelof
13.*

Of the 50, 5 must include 10 before and after photos each,
photos must be labelled as seen in the examples shown in this link: https://abhrs.org/wp-content/uploads/2022/08/AllPhotoViews-1.pdf
*

Cancelof
14.*

50 CME Credit Hours related to hair restoration surgery over preceding three (3) years of date of application.
*

Cancelof
Should be Empty:

ABHRS APPLICATION