For your convenience, we provided two types of forms: Online & Downloadable.  The Online Forms can be opened and completed with Adobe Reader.  After completion, the "Submit Form" button will automatically attach your completed Form to an email addressed to  The Downloadable Forms must be printed, completed and Faxed per instructions below.


For Online forms, fill in the appropriate fields and click submit.  Your Form will automatically be attached to a generated email and sent to PRO MED.  All Online Forms can be downloaded, printed and returned by Fax.

For downloadable forms only, select the form of your choice, download, print, and complete the form and fax to (407) 599-1994.  Our specialists will process your request as soon as possible. 

To view these files, you will need  Adobe Acrobat Reader installed on your PC.   If you do not have Adobe Acrobat Reader installed on your computer, click on the Adobe button below.

For additional information from the US Department of Heath & Humans Services click below.

Centers for Medicare &Medicaid Services