Secure ID and Insurance Card Submission

1

Patient Name* This field is required.

First Name

Last Name

2

Patient 's Date of Birth* This field is required.

Date

3

Insurance Card Subscriber Name

First Name

Last Name

4

Photo ID Submission - Front* This field is required.Please submit a front image of a current, valid photo ID for the patient. If the patient is a minor, please submit a photo ID for a parent/guardian.

5

Photo ID Submission - Back* This field is required.Please submit a back image of a current, valid photo ID for the patient. If the patient is a minor, please submit a photo ID for a parent/guardian.

6

Insurance Card Submission - Front* This field is required.Please submit a front image of the current insurance card for the patient. If the patient is not the subscriber, submit the subscriber's insurance card.

7

Insurance Card Submission - Back* This field is required.Please submit a back image of the current insurance card for the patient. If the patient is not the subscriber, submit the subscriber's insurance card.

8

Attestation: I am sending these ID and insurance card images for an individual who has already been referred, or is already an established patient at NW ADHD Treatment Center. I attest that I am authorized to hold and transmit images of these ID and insurance cards.* This field is required.

I agree and understand the above. I am submitting these records on behalf of an individual who is an established patient at Northwest ADHD Treatment Center.

9

EmailPlease enter an e-mail address if you would like to receive confirmation of your submission.

example@example.com