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This online form is to be used by medical professionals only. If you or a member of your household have a qualifying medical condition, doctors can submit the medical certificate to us online. Please email us or call Customer Service for details on the information your doctor will need to complete the medical form.
STEP 1 OF 4
Unique ID
Unique ID
Confirm Address
Required Info
Review & Submit
We appreciate your efforts to electronically complete the medical certificate for our customer. Please enter the Unique ID that you received from your patient below and click Next to continue.
If you are having issues with the Unique ID please call the med cert department at (1-866-596-1783) with any questions.
