Provider Document Upload

Provider Document Upload
Choose "Upload Document" to attach a document. After the document is attached, click the "SUBMIT" button. Once your document is submitted, you will get a confirmation number showing that the documents were successfully received.
PRIM ID
Provider License Number
(Recommended)
Email*
Enter Email Confirm Email
Submitter's Name*
First Last
What form does this document apply to?*
Documents*
Drop files here or

Accepted file types: jpg, png, tiff, pdf, gif.