Membership Medical Freeze Request-page

Membership Medical Freeze Request

Membership Medical Freeze Request

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PLEASE NOTE:

Requests must be received 30 days in advance of the requested start date and are subject to the Member Services Manager’s approval.

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 request and must be faxed to DCFL at 919-545-2687 or emailed to: [email protected].
  • Freeze may be granted for a minimum of one month and a maximum of 6 months, in full monthly increments only.
  • Freeze does not have to begin on the first of the month.
  • There is no charge for the freeze. If a note is not received you will be charged $12 per month.
  • Freeze may be granted for a minimum of one month.
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Physician Note Checkbox
Max. file size: 50 MB.
Consent*