Additional Document Upload

Additional Document Upload
Person completing Upload:
Document Status:
MHC Staff Down Loaded Doc:
Client's Name*

First NameLast Name
Clients Birth Date*

MonthDayYear
Agency Rep Name*

First NameLast Name
Agency Rep Phone Number*
Please enter a valid phone number.
Ext.*
Please upload a clear copy of the document.
If you are using your phone, follow these two steps:

Take a clear photo of the document using your phone’s camera.
Upload the image directly from your photo gallery.
What documents are you uploading (click all that apply)*

IncomeInsurance CardPhoto IDOther
Does client have Medicare Rx plan (Part D)- Covering Medication:
Photo ID Front)*

Cancelof
Photo ID (Back)*

Cancelof
Insurance Card (Front)*

Cancelof
Insurance Card (Back)*

Cancelof
Medicare Part D Insurance Card (Front)*

Cancelof
Medicare Part D Insurance Card (Back)*

Cancelof
Income*

Cancelof
Other*

Cancelof
Should be Empty: