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 3.