Upload ID and Insurance Info
Please drag photos of new/updated ID and/or insurance below. Files need to be in one of the following formats: bmp, heic (iPhone), jpg/jpeg, png, or gif. Image sizes cannot exceed 10mb each. Please crop images or scan at a lower resolution if you are told the size is too large. If an image contains both front and back of a card, you do not need to upload it twice. This form can be submitted without all four image fields completed.
My Name
*
First Name
Last Name
Clinician's Name
*
Today's Date
*
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Month
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Day
Year
Date
Image of ID (Front)
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of
Image of ID (Back)
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of
Insurance Card (Front)
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of
Insurance Card (Back)
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of
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