Health Insurance ID Card secure upload

First Name

Last Name

Preferred Phone

What phone number may we call in the event of a necessary communication?

Please leave a voicemail if necessary

Please do not leave a voicemail

Your Therapist

If your therapist is not listed above, please enter here:

Our Secure Upload:

Upload Front of Health Insurance ID

Please upload the front of your Health Insurance ID Card with your smartphone or computer using the button on the far right.

Upload Back of Health Insurance ID

Please upload the back of your Health Insurance ID Card with your smartphone or computer using the button on the far right.

If you have any additional information for our office administration, please enter here: