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Send Us Your Documents

Upload your insurance card, photo ID, referral, or other paperwork before your visit. We’ll add it to your file.
This form is for documents only and is not monitored for medical questions or urgent concerns. For medical questions, prescription refills, or test results, please call us at 256-837-2271 or message us through the patient portal. If this is a medical emergency, call 911.
Patient Name

First NameLast Name
Patient Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your Name (if submitting for someone else)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail
Are you a new or existing patient?
Upcoming Appointment Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearLeave blank if you don’t have one scheduled.
What Are You Sending?

Other
Upload Your Documents

Photos or scans are fine. Please include both the front and back of insurance cards. File types accepted: pdf, doc, docx, xls, xlsx, csv, txt, jpg, jpeg, png, gif. Up to 5 files, 10 MB each.
Note About These Documents:
Optional. For example, “New insurance as of January.” Please don’t include medical questions here.
Acknowledgment:
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Should be Empty:

Send Us Your Documents