Proof Of Identity & Insurance FOR BERNALILLO, SANDOVAL & VALENCIA COUNTY ONLY. Intake forms are securely encrypted and HIPAA compliant. Proof Of Identity & Insurance ID # CLIENT FIRST NAME*CLIENT LAST NAME*CLIENT DOB* MM slash DD slash YYYY DATE* MM slash DD slash YYYY EMAIL* UPLOAD PHOTO OF MEDICAID OR PRIMARY INSURANCE CARD*Accepted file types: jpg, jpeg, png, gif.DO YOU HAVE SECONDARY INSURANCE?* YES NO UPLOAD PHOTO OF SECONDARY INSURANCE CARDAccepted file types: jpg, jpeg, png, gif.UPLOAD PHOTO OF YOUR DRIVER'S LICENSE, PASSPORT, OR LEGAL IDENTIFICATION*Accepted file types: jpg, jpeg, png, gif.
