The Foundation is working hard to identify additional healthcare providers with experience in treating and managing RLS. Although we offer 17 Quality Care Centers, there is still a need for providers in all 50 states. If you have RLS treatment experience, please complete the following to join our RLS Provider Network.

Healthcare Provider Information

Name

Address

Address 2

City

State

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP

Scheduling Email

Scheduling Phone

I manage:

Adults

Adolescents/ teens

Children

Number of new/follow-up RLS patients you treat in a month

0

1-5

6-10

11-15

16-20

21+

Specialty

Family Medicine

Internal Medicine

Neurology

Psychiatry

Sleep Medicine

Pediatrics

Other (please specify)

Professional Organization Memberships

AASM

AAN

Other (please specify)

Do you give the RLS Foundation permission to publish your contact information on www.rls.org as an experienced RLS healthcare provider?

Yes

No

Would you like patient materials (RLS Foundation brochure) for your clinic/office?

Yes

No