Photograph your Insurance Card

Take a photo of your ID and then select Use Photo

Front side

Front side

Front side

Retake? Go back without using photo

Front

Back

Select Appointment type

Appointment type

Workflow group

Please select a Provider

Please enter DOB of your choice to preview registration form

I am registering for

Myself

My dependent

DOB

Sex

Continue

Loading. Please wait..

.

.

.

.

.

Language

Confirmation message

Do you want to complete the Open questions?

Please select a Zip Code

Zipcode

Confirmation message

The updated details will be lost if you go back. Do you want to go back?

No Page

This is the first page of the Registration process

The person responsible for payment must be at least 18 years old. Please review if all the information entered for the person responsible for payment is correct. Once you revise the information, click Next to go to the next page.

Information provided is incorrect.

If you think this is a mistake. Please see the front desk staff and ask them to correct your information. Once they do try again from here.

Do you have an additional insurance to add for this visit?

Yes, I have another insurance

No, Continue process

Your session was expired. You refreshed your page and for security reasons we expired your session. Please go back to your email/text message click the link again and start the paperwork. Information you entered so far will be stored and you will be asked to verify your identity.

Do you have more insurance?

Additional info for medication

Please wait...

This might take a moment

Crop Image

You can adjust the card to fit in the frame by dragging the orange scale below the image before saving