PDF Embed

Special Needs Form

If you have a serious medical condition and would like to designate your account as special-needs status, please find the attached form that will need to be completed by your physician and returned to our office.  Upon receipt of the completed request form, your account will be designated for special-needs status for one year.   At the end of that time, your name will be removed from the list unless a new certification form is received from your physician.