Re-Certification Online Form

Recertification Application Online Form

IJCAHPO, 2025 Woodlane Drive, St. Paul, MN 55125

Applying for Recertification

1.    Previously Recertified

All applicants that have recertified previously need to submit the following:

-       Completed online application. (Online application to follow)

-       Complete and download the Sponsor/Employer Endorsement form here. You will be required to upload this form later in the application.

-       List of IJCAHPO CE credits earned within your 3-year certification cycle. Please remember no duplicate courses will be accepted. Complete and download the credit reporting form here. You will be required to upload this form later in the application.

2.    Initial Recertification

All applicants applying for their initial recertification need to submit the following:

-       Completed online application. (Online application to follow)

-       Complete and download the Sponsor/Employer Endorsement form here. You will be required to upload this form later in the application.

-       List of IJCAHPO CE credits earned within your 3-year certification cycle. Please remember no duplicate courses will be accepted. Complete and download the credit reporting form here. Include with the credit reporting form, all continuing education credit verification documents. You will be required to upload the credit reporting form and your credit verification documents later in the application.

3.    Late Recertification Submissions

All applicants applying for recertification that are currently in a non-certified, or inactive, status due non-renewal need to submit the following:

-       Completed online application. (Online application to follow)

-       Complete and download the Sponsor/Employer Endorsement form here. This form will be uploaded later in the application.

-       List of IJCAHPO CE credits earned within your 3-year certification cycle. Please remember no duplicate courses will be accepted. Complete and download the credit reporting form here. Include with the credit reporting form, all continuing education credit verification documents. You will be required to upload the credit reporting form and your credit verification documents later in the application.

-       If it has been over 12 months since your recertification date, please contact the Certification Department at (800) 284-3937 or (651) 731-2944.e form.

Helpful Tip with the Online Recertification Application

Have all supporting documentation, such as your Sponsor/Employer Endorsement and the copies of your credits, ready for uploading prior to beginning to complete the online application.

Recertification Audits

A percentage of recertification applications will be audited. Documentation of supporting continuing education credits earned will be required only of persons whose names are randomly selected for audit. Those chosen will be notified within 4 to 6 weeks of receipt of their application and will be asked to submit the verification within 30 days.

Applicant
Certification Category:*

COACCOACOTCOMTROUBCDOSOSA
Name:*

First NameMiddle NameLast NameSuffix
Name Change Document Upload:

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Drivers License, Divorce Decree or Marriage License Needed Cancelof
IJCAHPO ID:*
JCAHPO ID
Date of Birth:*

MonthDayYear
Date of Birth
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:*

Area CodePhone Number
Preferred Email:*
example@example.com
What race or ethnicity do you identify most with?*

Responsibility Statement

IJCAHPO's Responsibility for Certification and Recertification of Medical Personnel Performing Technical Ophthalmic Services for Ophthalmologists.

IJCAHPO is the federated organization of ophthalmological societies and associations which has been charged with certain responsibilities related to the education and utilization of allied health personnel in ophthalmology. To implement these goals, IJCAHPO has established criteria for training, examination, certification, and utilization at various levels of expertise for ophthalmic medical personnel.Certification by IJCAHPO indicates ONLY that the individual has fulfilled the eligibility requirements and successfully completed an examination for which the individual qualifies. Certification by IJCAHPO does NOT imply, by any criteria, that the individual is qualified as an independent practitioner.

Responsiblity Agreement
Applicable to COA, COT, COMT, OSA, ROUB, and CDOS applicants only

1. I shall perform, to the best of my ability, those technical ophthalmic services specifically delegated to me by a sponsoring ophthalmologist (or physician for ROUB and CDOS) according to his or her directions, instructions, and prescriptions.
2. I shall provide technical ophthalmic services only in the office of my sponsoring ophthalmologist (or physician for ROUB and CDOS), a medical clinic, or other medical facility.
Applicable to CCOA applicants only

3. I am currently employed by a corporation that does business within the ophthalmic community and, in my position, I will be interacting with ophthalmic professionals on a continuing basis.
Applicable to ALL applicants

4. I authorize IJCAHPO to communicate any violation of its rules or standards by me, my status of application or certification, and any matter involving me to state and federal authorities, employers, training programs, and others.
5. I agree not to make and to correct immediately any statements concerning my certification status which are or which become untrue or misleading. I agree to provide IJCAHPO confirmation as requested by IJCAHPO.
6. I release IJCAHPO, its officers, directors, agents, employers, committee members, and others for disciplinary action taken in good faith pursuant to the rules, standards, procedures, and sanctions of IJCAHPO.
7. I authorize IJCAHPO in its discretion to request information concerning matters relevant to this application and my certification, recertification, and review of certification.
Please respond to the following questions that apply to you:

I have had a certification or license suspended or revoked.I have been dismissed from a job because of alcohol or other drug dependency.I have been convicted of a crime. (If "yes", please provided verification of penalty completion (Upload below)
If you replied to any of the above, please provide a brief explanation and a copy of verification of penalty completion:

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9. I have received and read the rules, standards, procedures and sanctions of IJCAHPO. I comply with and agree to be bound by them.
10. I affirm that all statements made in the above application are true.
Affirmation Signature:*

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Download the Sponsor/Employer Endorsement form here. This form will be uploaded below.
Upload Sponsor or Employer Endorsement:*

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Download the credit reporting form here.
Upload Credit Reporting Form and verification of credits if required:*

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OSA Surgical Log Upload:

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FOR ALL APPLICANTS
I attest that I have completed the minimum number of hours of continuing education credits required, that documentation is available and will be submitted upon request by IJCAHPO, and that the information provided herein is true and correct to the best of my knowledge. I understand that providing false information on this form may result in suspension or revocation of my IJCAHPO certification.
Applicant's Signature:

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Payer:*

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Card Holder Name:*

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Batch #
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Additional Fees:

$50 Rush Fee (typical 4-6 weeks, RUSH 1 week)Late fee $85 if you're past your recert date
Application Cost:
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