• Photo & Additional Information Submission

    Follow the steps below to submit photos of your condition or your picture ID. You may also use this form to submit additional information about your case to your provider.

  • IMPORTANT NOTE

    This form should only be used if you are uploading photos or information for a case in which you have not yet received a treatment plan.

    If you are requesting a refill, need new or additional treatment, or have already received a treatment plan, you must submit a new or follow up case here >>

  • PLEASE VERIFY

    You entered your provider's last name as:

    {whatIs}

    Are you sure you entered the correct name and spelling for your provider? We could not find a match.

    If you are unsure of your provider's name, you may continue with your upload(s) and our team will attempt to manually locate your submission.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancel of
  • Should be Empty: