QCC Application

The online application must be completed by all organizations seeking a new certification for the facility and by each healthcare provider seeking RLS certified provider status. The intent of the application is to certify a healthcare center and individual provider(s) for a six year period. A committee of the RLS Foundation’s Scientific and Medical Advisory Board (SMAB) will review application materials submitted against all certification criteria submitted for consideration; at least one committee member is internationally located. For technical assistance in completing the application, contact Executive Director, Karla Dzienkowski (karla@rls.org) or by phone at 512.366.9109.

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* 1. Date of application

Date of Application

Date

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* 2. $500 certification fee paid by:

check in USD

credit card

money order or wire

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* 3. Full name of Candidate Center seeking designation

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* 4. Full Name and Address of Candidate Center Seeking Certification

Name

Street

City

State

Zip code

Country

Telephone

Contact info for appointments

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* 5. Name of Center Director (MD or PhD required)

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* 6. Director holds an MD or PhD (or PhD equivalent) degree

Yes

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* 7. Name of Center Coordinator

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* 8. Center Coordinator's email

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* 9. Name of person completing this application

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* 10. Job title

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* 11. List clinicians applying for certification. Each to complete a clinician application here: https://www.surveymonkey.com/r/QCCClinician

Name

Organizational Capabilities

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* 12. Practice Guidelines. The Candidate Center should have experience managing RLS patients with a range of complexity and comorbidities using approved and off-label medications. Provide a description of practice guidelines and RLS recommendations implemented at this center(e.g., RLS Foundation treatment algorithm, AASM treatment guidelines).

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* 13. Available Services. List and briefly describe the diagnostic and therapeutic services currently offered to individuals with RLS and their families. The Candidate Center must have timely access to and geographic proximity to the following:

	Location	Distance
an American Academy of Sleep Medicine (AASM) or European Sleep Research Society (ESRS) accredited Sleep Center where polysomnography can be performed for selected patients when indicated	an American Academy of Sleep Medicine (AASM) or European Sleep Research Society (ESRS) accredited Sleep Center where polysomnography can be performed for selected patients when indicated Location menu	an American Academy of Sleep Medicine (AASM) or European Sleep Research Society (ESRS) accredited Sleep Center where polysomnography can be performed for selected patients when indicated Distance menu
psychiatry, neurology, and pulmonary consultants (if not members of the Center); hematology consultants; and services for the comprehensive management of sleep apnea, including surgical and dental consultants; psychiatrists are necessary because of frequent depression or anxiety comorbidity with RLS	psychiatry, neurology, and pulmonary consultants (if not members of the Center); hematology consultants; and services for the comprehensive management of sleep apnea, including surgical and dental consultants; psychiatrists are necessary because of frequent depression or anxiety comorbidity with RLS Location menu	psychiatry, neurology, and pulmonary consultants (if not members of the Center); hematology consultants; and services for the comprehensive management of sleep apnea, including surgical and dental consultants; psychiatrists are necessary because of frequent depression or anxiety comorbidity with RLS Distance menu
an MRI scan, an EMG laboratory, and a laboratory that can test serum ferritin and other iron indices	an MRI scan, an EMG laboratory, and a laboratory that can test serum ferritin and other iron indices Location menu	an MRI scan, an EMG laboratory, and a laboratory that can test serum ferritin and other iron indices Distance menu
access to actigraphy is desirable but not required	access to actigraphy is desirable but not required Location menu	access to actigraphy is desirable but not required Distance menu

Other (please describe)

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* 14. Infrastructure. Briefly describe the Candidate Center infrastructure. This includes the adequacy of office space and other physical facilities. The Center should have at least one administrative assistant and at least one nurse or clinical coordinator. Patients should have easy access to the Center by telephone and/or electronic means between appointments with a timely response to their concerns while maintaining HIPPA. Please address how immediate follow-up will occur if the Candidate Center does not employ a nurse or clinical coordinator.

Administrative Assistant

Nurse or Clinical Coordinator

Describe patient access between scheduled appointments

Case Records. Candidate Centers will submit for review six de-identified case records of RLS patients treated for at least one year. Records must be translated into English and contain a section header indicating the case and treatment used for each of the six de-identified patient records. These records must demonstrate experience with the following treatment modalities:

Case 1: Dopaminergic agents
Case 2: Alpha-2-delta ligands
Case 3: Opioids
Case 4: Iron deficiency
Case 5: Augmentation management
Case 6: Dopaminergic side effects management