Paul B. Zimmerman, Inc. PCP Upload

Please upload your completed Physician Form by 5/1/2025.

Before submitting your form:
• Print clearly
• Make sure your form is signed. Your signature is required
• Confirm your screening date falls within the acceptable range: 1/1/2025-5/1/2025

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.