American Express Physician Form

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  • Physician Form Secure Submission

    Screenings must be COMPLETED by 6/30/2026 and the form must be RECEIVED by 7/7/2026.

    Before you submit your form, please complete the following steps:

    • Print clearly and review your form to ensure it is complete.
    • Confirm the date of screening is within the following date range: 7/1/2025-6/30/2026.
    • Be sure to provide a valid email address so we can communicate with you regarding the status of your form.
    • Ensure you and your doctor have signed your form. Both signatures are required.

     

    Please reach out to WebMD Customer Service at 888-713-2837 with any questions.







  • Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 50 MB.