You should submit AC Form 8060-56 (PDF) to:
Federal Aviation Administration
Aerospace Medical Certification Division, AAM-331
ATTN: Duplicate Desk
Post Office Box 26200
Oklahoma City, Oklahoma 73125
You must include a check or money order for $2.00 made payable to the FAA.
If you have questions or need additional information, call (405) 954-4821 and select option 1.