Identity Health Clinic- ID + Insurance Form
Form for Uploading Driver's License and Insurance Card Images, Front and Back. Cell phone photos are fine.
Patient Name
*
Guardian Name if Applicable
Guardian Relationship to Patient if Applicable
Email Address
*
Driver's License (Front) - If Patient Is under 18 Please Upload Parent/Guardian ID
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Insurance Card (Front)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Insurance Card (Back)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If you are uninsured we are able to see you as a Self Pay patient Please write 'Self Pay' in the Box below to alert staff.
If you are a current patient, how does this impact your insurance already on file?
Please Select
This replaces insurance currently on file
This is primary to insurance currently on file
This is secondary to insurance currently on file
My insurance is complicated, please call to assure accuracy
What is the effective date of this change?
-
Month
-
Day
Year
Date
Submit
Should be Empty: