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 Name

Middle Name

Last Name

Patient Date of Birth

Date

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

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

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

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

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.

📎

Select Image of Government Issued ID

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

Do you have SECONDARY insurance?

Yes

No

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

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

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

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)