Secure Document Upload
Please use this HIPAA compliant form to upload documents requested by staff.
Submission Date
*
/
Month
/
Day
Year
Date
Client Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
We require the following forms prior to moving in.
Client photo
Copy of ID (front and back)
If available please provide the following:
Proof of Insurance
Proof of Income
Proof of tribal affiliation/copy of Tribal ID
File Upload Option (use for file upload instead of camera)
Browse Files
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of
Required, Client Photo
Required, Front of ID
Required, Back of ID
If applicable, Front of Insurance Card
If applicable, Back of Insurance Card
If applicable, Proof of Income
If Applicable, Proof of Tribal Affiliation
Submit
Should be Empty: