CLICK TO CALL

Proof of Identity & Insurance

Proof of Identity and Insurance (if available) is needed to complete a successful application process.

Provide clear photos (or scans) of Parental identity (for minors under 18 application), and Patient identity (over 18) by submitting a valid drivers license (front), passport (ID page), or green card (front). Also include a proof of insurance (if available) (please submit the front and back of your insurance card). 

NOTE: Proof of Identity & Insurance (if available) is a required form submission. 

Proof of Identity & Insurance

Contact Information

Name(Required)
Adult patient, parent or guardian
Name of Patient (if under 18)
Adult patient, parent or guardian
Adult patient, parent or guardian
Address(Required)
Adult patient, parent or guardian

Identification

Drop files here or
Max. file size: 32 MB.
    Accepted file types: jpg, jpeg, png, gif, pdf.

    Proof of Insurance

    Drop files here or
    Max. file size: 32 MB.
      Accepted file types: jpg, jpeg, png, gif, pdf. | Please submit both front and back of the card.

      Return to Telehealth Registration page

      © 2024 Southern Indiana Community Health Care.   PRIVACY

      Social Media

      FacebookYouTubeLinkedInEmail
      TOP