Veteran Self-Certification

Veteran Certification Form

This form is ONLY for Veterans, and you must be able to provide a veteran identification card to be eligible.

If you are a Veteran and new to the program, please proceed with submitting the certification form below.
If you are a Veteran who is currently enrolled in this program AND your current enrollment has already expired or is set to expire within the next 90 days, you can submit this certification form INSTEAD of getting recertified by your Health Care Practitioner.
If you are a Veteran who is currently enrolled in this program BUT your enrollment is NOT expired yet or set to expire within the next 90 days, you must wait until you are eligible for recertification to submit this special Veteran’s certification form.
If you are NOT a Veteran, please see information on the general enrollment process HERE.

VETERANS, PLEASE NOTE: If you prefer, you can still opt to go through the enrollment process by getting certified by a registered Health Care Practitioner. If you choose to enroll through your Health Care Practitioner, please contact them directly for certification.

Personal Information

* indicates a required field.

Email Address *

Please confirm that your email address is correct. Incorrect email addresses will delay your enrollment process.

First Name *

Middle Initial

Last Name *

Date of Birth (mm/dd/yyyy) *

Phone Number (###) ###-#### *

Veteran Verification Document

Please click "Upload" below to submit an image of your veteran identification card. The only acceptable file formats are JPEG, JPG, PNG, GIF, TIF, or BMP. We cannot accept PDF files.

Please ensure the image is clear and all of the text is legible before you submit this form.

Upload

No file(s) uploaded

Please check this box to review and accept the legal acknowledgement, consent, and disclosure statements.

	Alzheimer's Disease
	Amyotrophic Lateral Sclerosis (ALS) / Lou Gehrig's Disease
	Autism Spectrum Disorder
	Cancer - Cachexia or severe wasting
	Cancer - Nausea or severe vomiting
	Cancer - Severe or chronic pain
	Chronic Pain, including Intractable Pain
	Chronic Vocal or Motor Tic Disorder
	Glaucoma
	Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)
	Inflammatory Bowel Disease, including Crohn's Disease
	Irritable Bowel Syndrome (IBS)
	Muscle spasms (severe and persistent), including those characteristic of Multiple Sclerosis (MS)
	Obsessive-Compulsive Disorder (OCD)
	Obstructive Sleep Apnea
	Post-Traumatic Stress Disorder (PTSD)
	Seizures, including those characteristic of Epilepsy
	Sickle Cell Disease
	Terminal Illness - Cachexia or severe wasting
	Terminal Illness - Nausea or severe vomiting
	Terminal Illness - Severe or chronic pain
	Tourette Syndrome

Veteran Certification Form

Personal Information

Patient Medical Diagnosis

Veteran Verification Document