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 info@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.