Membership Medical Freeze Request-page

Membership Medical Freeze Request

Membership Medical Freeze Request

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PLEASE NOTE:

Physician’s note with the start and end date must be attached to implement the freeze. Requests without a note attached, and that do not follow the date range parameters will NOT be implemented.

1. Complete Member Information.

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MEDICAL FREEZE

  • Physician’s note must be received to implement the freeze clearly stating the reason for the freeze with a START AND END date.
  • The freeze can start on any day of the month.
  • If you wish to return sooner than the physician’s recommendation, they will need to submit another note clearing you for exercise.
  • There is no charge for the freeze. If a note is not received, $12 will be charged per month.
  • Upload the note here, fax to: 919-545-2687, drop off at DCFL front desk, or email to: [email protected].
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Max. file size: 50 MB.
Consent*