Secure Document Upload
Please use this HIPAA compliant form to upload documents requested by staff.
Submission Date
*
/
Month
/
Day
Year
Date
Client Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
If available please provide the following:
Client photo
Copy of ID (front and back)
Proof of Insurance
Proof of Income
Proof of tribal affiliation/copy of Tribal ID
File Upload Option (use for file upload instead of camera)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Client Photo
Front of ID
Back of ID
Front of Insurance Card
Back of Insurance Card
Proof of Income
Proof of Tribal Affiliation
Submit
Should be Empty: