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Make sure you press the "Submit" button at the bottom when finished uploading all appropriate documents.

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Photo ID (driver's license, permanent resident card, or passport) *

Max file size: 20MB

Current Utility Bill/Lease in Patient's Name with Current Address *

Max file size: 20MB

Federal Taxes Form 1040 *

Max file size: 20MB

Social Security/TIN Card *

Max file size: 20MB

Insurance Card *

Max file size: 20MB

PLEASE UPLOAD ALL OF THE FOLLOWING DOCUMENTS THAT APPLY TO YOU

Business Taxes for the Most Recent Tax Year
Latest Quarterly Filing
90 Days of Business Bank Statements
Business Profit/Loss Statement for Current Year
60 Days of Most Recent Pay Stubs
Social Security or Supplement Security Income Award Letter
Veteran Benefits Award Letter
Pension or Retirement Award Letter or Statement
Unemployment Award Letter
Verification of Alimony

Verification of Child Support
Workers Compensation Award Letter
SNAP Letter
TANF or Transitional TANF Assistance
Housing Assistance Letter
Owned Rental or Investment Property Documentation
Stocks, Bonds, CDs, 401K Statements
90 Days of Most Recent Bank Statements for each Account Owned
Verification of Support Form

DOCUMENT 1 *

Max file size: 20MB

DOCUMENT 2 *

Max file size: 20MB

DOCUMENT 3 *

Max file size: 20MB

DOCUMENT 4 *

Max file size: 20MB

DOCUMENT 5 *

Max file size: 20MB

DOCUMENT 6 *

Max file size: 20MB

DOCUMENT 7 *

Max file size: 20MB

DOCUMENT 8 *

Max file size: 20MB

DOCUMENT 9 *

Max file size: 20MB

DOCUMENT 10 *

Max file size: 20MB

DOCUMENT 11 *

Max file size: 20MB

DOCUMENT 12 *

Max file size: 20MB

Submit

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