CAQ Route for Physicians New to the Specialty: Application Checklist

ABHRS APPLICATION:

Certificate of Added Qualification (CAQ) 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:*
ALL REQUIREMENTS MUST BE SUBMITTED IN ENGLISH
1.*

Signed Application
(Complete and Submit this Form: https://hipaa.jotform.com/222200514236137)
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/222202803536143)
5.*

Current and valid Life Support with External Defibrillator (“BLS/ED”)
certification from https://www.onlineaha.org/
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/222202489823152)
9.*

Application Fee payable upon submission of application.
Note: Written examination fee is payable upon approval of application
Cancelof
10.*

Proof attended 2 ISHRS annual meetings
Cancelof
11.*

Proof attended 16 hours live surgical workshop
Cancelof
12.*

25 Case Logs as primary surgeon. See example shown in this link: https://abhrs.org/wp-content/uploads/2022/08/Case-Logs-updated-4.16.14.pdf
Cancelof
Should be Empty:

ABHRS APPLICATION:

ALL REQUIREMENTS MUST BE SUBMITTED IN ENGLISH