Landing Page - Uploader

Before you submit your form, make sure you have:

Completed top section of form
- Step 1 and 2: Fill out your information AND include email address in its entirety.
- Step 3: Ensure YOU have signed your form. Without your signature, this form will not be accepted.
Asked your physician to complete Step 3 in its entirety.

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.

First Name

Last Name

Date of Birth Date Format: YYYY-MM-DD

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