TOMC / CPC- ID Card Submission Form

Identification Card Submission Form
Please send us a photo of the front side of your Driver's License of state identification card. This is important for verifying your identity when billing your insurance. For minors, please send the identification card of the parent or guardian.
Date

Month Day Year
Date
Client's Full Name *

First Name Last Name
Client's DOB *
Email
example@example.com
Is the client a minor or dependent adult? *

Yes No
Parent / Guardian's Name

First Name Last Name
Please take a picture of the front of the ID card *
We know this is a little tricky...Position the card so that it is close enough to fill most of the screen and straight as possible. Make sure the lighting is good, and watch your fingers!
Should be Empty:

Identification Card Submission Form