Insurance Card Information
I prefer to pay out of pocket? (Please know instructions will be provided upon receipt of this information.).
I will pay out of pocket
I will pay with insurance
Front Side Insurance Card:
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Back Side Insurance Card:
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Front Side Photo ID (Drivers License Preferred. This is to prove that the insurance belongs to you):
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Preferred ways to pay copay or coinsurance:
PayPal (Please know that this is not a HIPAA compliant option.)
Venmo (Please know that this is not a HIPAA compliant option.)
Squareup
Sending a check by mail (Please send to the Santa Fe address.)
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Should be Empty: