Certification Status Re-Establishment Form

Name(Required)
Has your name change since your certification has expired?(Required)
Mailing Address(Required)
Email Address(Required)

Expired Certification Information

Please list the Certification(s) that you would like to have re-established with the AIHCP(Required)
Certification Name
Issue Date of Certification
 
You may use an approximate issue date if you cannot react the exact one.

Current Status Information

AIHCP needs the following information on your current status to evaluate your application for re-establishment of certification
Are you currently a Licensed Health Care Professional?(Required)
Are you actively working in your health care professional role?(Required)
Are you currently retired from work in health care?(Required)

Status of Continuing Education

Have you acquired a minimum 50 CE (contact hours of education) within the last 6 years?(Required)
CE hours do not have to be in your area of certification specialty, but must be related to health care.

Optional