EYEZ10 Insurance Card & DL Form

To expedite your benefits confirmation, please upload a copy of the front and back of your insurance card and government issured ID, 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 PRIMARY insurance card. *

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

Cancelof
Do you have secondary insurance?

YesNo
Please attach a photo of the FRONT side of your SECONDARY insurance card. *

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

Cancelof
Please attach a photo of your government issued ID (driver’s license, passport or military ID, etc.).

Cancelof
Should be Empty: