Physician Form Secure Submission

Upload your completed Physician Form by 9/15/2025.

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: 9/1/2024 – 9/15/2025.
• 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.
• If both you and your eligible spouse have submitted a physician form, please be advised to upload each form separately as they will be processed individually. If multiple forms were sent, only the first form received will be processed.