Certco Inc. PCP Upload

Phone

This field is for validation purposes and should be left unchanged.

Please upload your completed Physician Form by 4/30/2027.

Before submitting your form:
• Print clearly
• Make sure your form is signed. Your signature and your physician's signature are required
• Confirm your screening date falls within the acceptable range: 11/1/2026-4/30/2027

First Name*

Last Name*

Email Address*

Please attach your signed PCP form. All submissions must include an attachment.*

Accepted file types: jpg, gift, png, pdf, Max. file size: 50 MB.