The online application is for all clinicians seeking RLS certified provider status at an RLS Foundation Quality Care Center for period of six years.  The RLS Foundation’s Scientific and Medical Advisory Board will review application materials submitted against all certification criteria.  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. Clinician's Name

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* 2. Quality Care Center Name and Location

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* 3. Degree(s) and titles

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* 4. Board certification(s)

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* 5. Licensed in State(s)

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* 6. # of years in profession

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* 7. # of years experience treating RLS

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* 8. Specialty area(s), if any

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* 9. Academic affiliations

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* 10. Primary duties

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* 11. Percent time at candidate center

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* 12. Part of institution staff?

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* 13. Each individual clinician must have seen at least 50 unique RLS patients. For PAs and APRNs, 50 unique RLS patients seen in aggregate with at least 25 patient encounters under the supervision of an MD (up to 25 unsupervised RLS patient encounters). Confirm that you meet that requirement.

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* 14. Each Quality Care Center clinician must fulfill ONE of the following:

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* 15. Upload a current CV or brief biosketch

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* 16. Upload a copy of current and active licensure.

Continuing Education (CME)
In the prior three years, MD and PhD candidates have completed at least 25 hours of Continuing Medical Education (CME) in sleep medicine or movement disorders neurology (with at least 6 hours specifically related to RLS). APP (Advance Practice Providers such as an APRN or PA) candidates will maintain their continuing education requirements, state licensure and certification as required by their licensing board of record (with at least 6 hours specifically related to RLS) in the prior three years. In addition to accredited CME (e.g., from the AMA), the following educational experiences can be counted toward the requirement for 25 hours of CME and 6 hours related to RLS. (The peer-reviewed article must be on sleep or movement disorders if it is applied to the 25 hour requirement and the article on RLS is applied to the 6 hour requirement.)

Please provide documentation of 25 CME hours in Sleep Medicine or Movement Disorders Neurology, with 6 hours specific to RLS in the prior three years or acceptable alternative CME provided to the committee. Alternative forms of acceptable CME:
  • The RLS Foundation’s Physician Education Webinar Series is an acceptable form of RLS-specific education for physicians, PAs and APRNs in the US and other countries. Each 1 hour, on-demand webinar attended will count as 1 hour toward the 6 hour requirement. The RLS Physician Education Webinar Series is a free, on-demand series of webinars available at https://www.rls.org/physicianed. A copy of the webinar registration for each webinar attended shall be provided to the Committee for review.
  • Alternative CME, similar to that adopted by other bodies is acceptable. Alternative CME for the US and all other countries includes authorship on peer review articles. In that case, each first or last authorship on a peer review article, other than a review article, shall be awarded 10 CME credit hours, and each authorship, other than first and last authorship, shall be awarded 5 CME credit hours. No limitations are placed on the number of papers each applicant can submit for certification.
  • The Committee recognizes CME requirements differ between the US and other countries. For US providers seeking certification from outside the US, a certificate of attendance for each education event shall be provided to the Committee for review. The educational event attended need not be an official CME event.
  • The Committee recognizes alternative CME for presenters at conferences and seminars on RLS (national and international). Each 1 hour presentation will count as 1- hour toward the 6 hour RLS requirement or the 25 hour sleep or movement disorders requirement. No limitations are placed on the number of conference presentations each applicant can submit for certification.

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* 17. Continuing Education

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* 18. Upload CME certificate.

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* 19. Continuing Education

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* 20. Upload CME certificate.

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* 21. Continuing Education

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* 22. Upload CME certificate.

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* 23. Continuing Education

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* 24. Upload CME certificate.

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* 25. Continuing Education

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* 26. Upload CME certificate.

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* 27. Continuing Education

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* 28. Upload CME certificate.

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* 29. Total number of CME's submitted here.

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* 30. Please provide any additional Comments or Questions.

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