Upload all applicable / completed forms here:

CLICK HERE to go back to the landing page where you can access detailed instructions on how to reduce your monthly medical plan contribution and avoid monthly medical plan surcharges in 2022. You can also access all applicable forms on this page.  

 

Before you submit your form (s), make sure you:

Step 1: Fill out your information completely and include an email address.

Step 2: Ensure you have signed your form. Without your signature, this form will not be accepted.

Step 3: Ask your doctor to fully complete their section of the form, according to the instructions on the form.

To submit your form(s), complete the fields below. Click "Select a File" to upload your form(s), then click the "Upload Form(s)" button

Personal Details
 Date Format: YYYY-MM-DD
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For assistance, please contact US Wellness at support@uswellness.com or 301-926-6099 X900.