Before you submit your form, make sure you have:

To submit your form, complete the fields below. "Click 'Select a file" to load your document or a picture of your form, then click Upload Form.

Forms submitted July 1, 2022-June 30, 2023 will count toward the 2023/2024 medical premium. 



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For assistance regarding your physician form, please contact US Wellness at (301) 926-6099 x900.