Insurance Card Upload Form

This form is to send us your insurance card securely. Please use the fields below and submit when finished.

BMC Troy

Upload Primary Health Insurance Card

Effective Date:

FRONT of card

Please select an image size 2 MB or less.

BACK of card

Please select an image size 2 MB or less.

Do you have secondary insurance?

Yes

No

Upload Secondary Health Insurance Card

Effective Date:

FRONT of card

Please select an image size 2 MB or less.

BACK of card

Please select an image size 2 MB or less.

Patient first name

Patient last name

Birthdate

Date: