Recertification Online Form

Fields marked with an * are required

Phone Number Instructions
When entering your phone number below, do not add the leading 1 digit.
Examples:
WRONG:  1 (555) XXX-XXXX
CORRECT: (555) XXX-XXXX


*IMPORTANT*

Submitting this online form is only one half of the online recertification submission process. You will need to call:1-877-262-9259 to provide your NAME and SOCIAL SECURITY NUMBER. This information will be matched to the information you have already submitted online.

This extra step is provided as an extra layer of security in the protection of your personal information.

If you do not call and complete your submission, we will be unable to process your request.