Health Care Provider Form Secure Submission
Upload your completed Health Care Provider Form by 11/30/2024.
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: 12/1/2023 – 11/30/2024.
- Be sure to provide a valid email address so we can communicate with you regarding the status of your form.
- Ensure you have signed your form. Your signature is required.