INTZ03 Insurance Card and ID Image Form

Insurance Card and ID 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 PRIMARY insurance card. *

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

Cancelof
Please attach a photo of the patient’s government issued ID. If the patient is a minor, please attach a photo of the parent/guardian’s ID. Acceptable IDs include driver’s license, passport, military ID, etc. Please ensure that these IDs are valid and not expired.

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
Should be Empty: