Click Here to Submit the Informed Consent for Telehealth
Click Here to Submit the Credit Card Authorization Form
Click Here to Submit the Scholarship Application (Income must be < $120k)
Click Here to Submit the Community Sponsorship Agreement (Medicaid)
Click Here to Submit the Authorization to Release PHI
Download the file to your computer and open the file in a PDF viewer (e.g. Adobe or Preview) before you fill it out. Remember to save the file before uploading it.
• FRONT and BACK of Insurance Card
• FRONT of Driver's License
You are exempt from providing documents verifying your income information due to your age.
• Two Most Recent Paystubs
• IRS W2 Tax From
• IRS 1040 Tax Form