This page offers a convenient and secure way to upload documents to our office for review and processing.
Relationship to Patient:
I am the patient and over 18 years of age
I am a Health Care Provider
I am a Pharmacy Provider
I am a Reimbursement Services Provider
I am the Parent/Guardian of a Minor
I am acting on behalf of an adult
Patient Full Name:
Patient date of birth: (mm/dd/yyyy)
Submitter phone number:
If provided on source communication or by Patient Advocate.
I am the patient or I have permission from the patient to upload documents on their behalf
There is a maximum of 5 attachments at a time.
To add an additional file click the "Add another file" link.
Each file can be no more than 5 MB.
Acceptable file types are: .doc, .docx, .xlsx, .xls, .pdf, .jpg, .png, .txt, .jpeg
To avoid possible issues with the upload, the file name should just include letters and/or numbers.
There is a limit of 5 attachments in a single upload.
Health Insurance Plan Details
Power of Attorney Documentation
Program Agreements/HIPAA Documentation
If you are experiencing technical difficulty
or need assistance uploading documentation,
please contact a patient advocate.
9 am - 6 pm EST
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