Form for Uploading Face Picture and Copy of Health Insurance Card

.... 2017-2018


Capitalize name appropriately... No all caps, please


Capitalize name appropriately... No all caps, please


Only if you have one... Capitalize name appropriately... No all caps, please


PLEASE format date as -- mm/dd/yyyy


PLEASE upload a good quality photo of your face (drivers license/passport type picture). A selfie is just fine, as long as it is focused and taken with good lighting.

ALSO upload a photo of the FRONT AND BACK of your health insurance card.

If you do not have these two items available when filling this form, you may copy AND save the link below and use it later to upload these two items:

https://goo.gl/xtG2ng







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