Physician Form Secure Submission
Upload your completed Physician Form by March 31, 2023. Submitting prior to March 1 or earlier is highly recommended to allow time for processing. It is the member’s responsibility to ensure the form has been received and approved.
Before you submit your form, please complete the following steps:
- Print clearly and review your form to ensure all fields are complete.
- Confirm the date of screening is within the following date range: April 2, 2022 – March 31, 2023
- Be sure to provide a valid email address so we can communicate with you regarding the status of your form. Watch for an email from email@example.com. If you do not receive an email confirmation within 48 hours call 888.434.4358 x127.
- Ensure that you and your physician have signed your form. These signatures are required.