THEZ05 Insurance Card Form

Insurance Card Image Submission
To expedite your benefits confirmation, please upload a copy of the front and back of your insurance card, then press submit.

(You can use your cell phone to take the picture of each side.)
Patient Name*

First NameMiddle NameLast Name
Patient Date of Birth

MonthDayYear
Date
Please attach a photo of the FRONT side of your insurance card. *

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Please attach a photo of the BACK side of your insurance card. *

Cancelof
Should be Empty: