• Medical Certificate Form

  • Thank you for opting to pre-pay your medical certification application fee online.

  • Section 1

  • This need to be completed by member/patient.

  • Claim Detail

  • Section 2

  • This need to be completed by Medical Practitioner.

  • I certify that in my opinion

  • First consulted me with signs or symptoms consistent with

  • In my professional opinion such signs and symptoms had been in evidence prior to this date for a period of

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