File Submission
Please make sure your physician/nurse team is aware of the file you are submitting. Submissions are handled during business hours only.
Full Name of who the file applies to
*
First Name
Middle Name
Last Name
Date of Birth of who the file applies to
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
E-mail
example@example.com
Select the provider to send to
*
Please Select
Davison
Derksen
Friesen
Froese
Gerlach
Goodnight
Green
Haag
Hemmen
Hilger
Huser
Kardatzke
Kenas
Kettner
Kovach
Lauer
May
Messner
Morrow
Nichols
Nguyen
Pfeifer
Raney
Raymond
Reichenberger
Gary Reiswig
Jeff Reiswig
Jeremy Reiswig
Justin Reiswig
Reed
Robl
Shaver
Smith
Stroberg
Ullom
Weippert
Yang
Other
Please Specify the File Type
Please Select
Insurance Card
Form
Photo
Other
What is the Legal Name of the Guarantor (who the insurance is under)
*
First Name
Middle Name
Last Name
Please list the legal name(s) and date of birth of patients at the clinic who will be covered by this insurance plan
*
Is this insurance primary or secondary?
*
Please Select
Primary
Secondary
Please make sure to provide front AND back of the card
Upload your files here
*
Click to upload
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Please provide a description of the files you are submitting and mechanism to return to you (if applicable)
*
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