Physician Certification in Wound Care Application Submission

Name *

First

Last

Email *

Photocopy of Drivers License *

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Photocopy of Medical School Diploma *

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Photocopy of Board Certification *

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Photocopy of State Medical License *

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Verification of completion of at least 20 hours of wound care based CME credit *

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Documentation of Membership in a Professional Wound Care Society *

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Curriculum Vitae *

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--- Letter of Verification from a program Medical Director or a hospital administrator --- documenting active status & good standing of professional credentialing *

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Personal Letter of Verification *

I certify that the information I have provided in this application is correct and complete, and understand that any certification granted me must be returned if I have falsified or omitted information. I further certify that I understand that certification is granted upon all of the information in my application, that there is no appeal for an adverse decision by the ABWH, and waive my rights to seek legal remedy should I not be certified at this time. In the event that I do not take this exam, I am entitled to a refund of $500. I also understand that being certified as a specialist in wound care will have a seven year life, after which recertification is necessary to maintain this distinction.

Wound Care treatments case log *

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