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Online HVA Certification Form

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This form allows submission of an Certification Application online with payment of applicable certification fee ($500/Member and $795/Non-Member*) by credit card. *Non-member fee includes ASDIN membership for remainder of the membership year from date of certification application.

If there are any issues in the upload/submission of this form, please use the following uplink -

https://spaces.hightail.com/uplink/asdin for file uploads and notify the ASDIN office at lfox@asdin.org.

DO NOT SEND PATIENT IDENTIFIERS IN ANY OF THE PAGES SUBMITTED. PLEASE REVIEW CASE/PROCEDURE NOTES, CASE LOG AND CQI DOCUMENTATION TO ASSURE THAT PATIENT NAMES ARE REMOVED. YOUR APPLICATION WILL BE RETURNED TO YOU AND WILL NOT BE PROCESSED UNTIL AN APPLICATION WITHOUT PATIENT IDENTIFIERS IS SUBMITTED.

First Name *
Last Name *
Email Address *
Are you currently ASDIN certified?Applicants must be currently certified by ASDIN in HVA and actively doing interventional procedures.	Yes - please use HVA Re-certification application No
Are you currently Board certified? *Applicants must be currently certified by the American Board of Internal Medicine in Nephrology, American Osteopathic Board of Internal Medicine in Nephrology, American Board of Radiology, American Board of Surgery or National Board of Physicians and Surgeons.	Yes No
Are you applying for certification in any Advanced Procedures? *	Yes - please designate below No
Select Advanced Procedures for which you are applying	Accessory Vein Obliteration Subcutaneous Port Placement Banding for dialysis-associated steal syndrome
Upload Completed Application *Applicants should only include the Application itself (pgs. 6-7) in this upload.
Upload Case Index and Case Notes *Applicants should only upload the required Case Index along with the Case/Procedure Notes in this file.
Upload CQI documentation *
Please provide the name and email address of the persons submitting your Peer Recommendations *
Formal Training Only - provide the name and email of the person submitting your Training Letter

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If there are any issues in the upload/submission of this form, please use the following uplink -