Attachment B Verification by the Appropriate Fellowship Program Director

Headache Medicine CERTIFICATION APPLICATION APPENDIX Sample Form Letters

Last Revised: 06/29/07

Attachment B – Verification by the Appropriate Fellowship Program Director Sample Letter

Certification Dept. UCNS 1080 Montreal Ave. St. Paul, MN 55116 [email protected]

Certification Dept:

This letter serves as documentation that has satisfactorily completed 12 months of UCNS-accredited fellowship training in Headache Medicine at . The training occurred from .

Sincerely,

Fellowship Program Director Address Phone E-mail

UCNS HM Certification Application Appendix - Sample Letters Page 1 of 4 Sample Attachment C – Documentation From Fellowship Program Directors Sample Letter

Certification Dept:

This letter serves as documentation that has satisfactorily completed 12 months of fellowship training (non-accredited) in Headache Medicine at . The training occurred from .

Sincerely,

Fellowship Program Director Address Phone E-mail

UCNS HM Certification Application Appendix - Sample Letters Page 2 of 4 Sample Attachment D – Letter From Department Chair Sample Letter

Certification Dept:

This letter serves as documentation that has had an active, full- time academic appointment at since . Teaching responsibilities include instructing in Headache Medicine.

Sincerely,

Department Chair Address Phone E-mail

UCNS HM Certification Application Appendix - Sample Letters Page 3 of 4 Sample Attachment E – Letters From Two Physicians Sample Letter

(The two letters must together address the entire 36-month period of time.)

Certification Dept:

This letter serves as documentation that I am familiar with ’s practice pattern over the last years. I can attest that at least 25% of ’s practice during the last 36 months has included direct diagnosis and management of Headache Medicine conditions.

Sincerely,

Address Phone E-mail

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