Boro Medical Insurance Information
Please use this form to upload your insurance card information so we can handle your information in the safest way possible.
Patient Name
*
First Name
Middle Name
Last Name
Policy Holder Name
*
First Name
Middle Name
Last Name
Please accept the following agreements so we can accept your information and handle it properly.
*
I agree to the
Privacy Policy
,
Terms and conditions
, and
Telehealth Consent
.
Patient Date of Birth
-
Month
-
Day
Year
Policy Holder Date of Birth
-
Month
-
Day
Year
Please upload a picture of the FRONT of your insurance card.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a picture of the BACK of your insurance card.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: