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Questions? Contact us at:

849 International Drive, 4th Floor, Linthicum, MD, 21090, US

Patient/Caregiver Registration Inactivation Request Form

Please note that once the account has been inactivated, it cannot be recovered/reactivated. In order to become a patient or caregiver again a new application would need to be submitted, including the non-refundable registration fee ($25).


If you have a physical ID card, you must send it back to the MCA at the following address: 

849 International Drive, 4th Floor, Linthicum, MD 21090

Date of Request

Date Picker

Patient Information

Full Name of Patient

Patient's Address

Caregiver Information

Full Name of Caregiver

Caregiver's Address

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