Insurance Form

Please fill out and upload proof of health insurance coverage or proof of enrollment in a health care sharing program.

Insurance Form

First Name

Last Name

Email*

Scan and upload a copy of your insurance card*Please include both the front and back of your card. If you are part of a health care sharing program, upload a proof of enrollment.

I certify that the information entered here is accurate, and that my electronic signature is the equivalent to my handwritten signature.

Signed: