Physician's Certification of Medical Condition - UnitedHealthcare Children's Foundation

Physician’s Certification of Medical Condition

One of the required documents that we must receive with your child’s application is a certification from your child’s physician of the medical condition(s) relating to the items you are seeking assistance.

Please review and follow the guidelines below to complete this requirement.

  1. Download and print a copy of the Physician’s Certification of Medical Condition Form.
  2. Complete the top portion of form and provide to your child’s physician to complete the bottom portion.
  3. The form MUST be completed and signed by an M.D. (Doctor of Medicine), D.O. (Doctor of Osteopathic Medicine), or for hearing-relating conditions, an Au.D. (Doctor of Audiology) within the last 6 months.
  4. After you receive the completed form back from your child’s physician, please scan a copy to your computer (you may also take a picture of each side) and attach it to your child’s grant application when submitting online.