Insurance Submission

Upload Front of Insurance Card
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Upload Back of Insurance Card
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Upload Gov Issued ID
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Type of Referral
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Do you have the patients SSN?
Does the patient have a guardian?
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Is the patient of Hispanic or Latin origin?
Has the patient participaed in a self-help group in the past 30 days?
Is the patient a veteran?
Is the patient pregnant? (Female only)
Upload Front of Insurance Card
Upload supported file (Max 15MB)
Upload Back of Insurace Card
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Upload File
Upload supported file (Max 15MB)
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Do you have the primary care info?
Are you a hurricane victim
Is the patient currently recieving mental health treatment
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Any arrests in the past 30 days?
Upload File
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Your Signature