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.

Contact Information

Name(Required)

First Last

Adult patient, parent or guardian

Name of Patient (if under 18)

First Last

Phone(Required)

Adult patient, parent or guardian

Email(Required)

Adult patient, parent or guardian

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Adult patient, parent or guardian

Message to SICHC (if any)

Identification

ID Upload - Document(s)

Drop files here or

Max. file size: 32 MB.

Accepted file types: jpg, jpeg, png, gif, pdf.

Proof of Insurance

Proof of Insurance Upload - Document(s)

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.

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Proof of Identity & Insurance