Membership Medical Freeze Request

"*" indicates required fields

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.

MM slash DD slash YYYY

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.
  • 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.
MM slash DD slash YYYY
MM slash DD slash YYYY
Max. file size: 50 MB.
Consent*
Duke Center For Living at Fearrington
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