Photo ID Submission

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Photo ID Submission

At Peace Psychiatry, we need photo identification in order to provide services to you. If the patient is under 18, then a parent/guardian should be submitting their ID. Please upload a clear picture of your Photo ID here, otherwise you may email pictures to general@peacepsychiatry.com.

3Questions

HIPAA

Compliance

1
Patient Name* This field is required.
First Name
Last Name
2
Patient's Date of Birth* This field is required.
Month
Day
Year
3
Upload PHOTO ID here* This field is required.If patient is under 18, then a parent or guardian photo ID is acceptable
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
4
PHOTO ID - please make sure picture is CLEAR/focused! (you should see a preview here)
Should be Empty:

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