Upload A DocumentHannah Hippe2023-11-21T12:52:47-06:00 Upload A Document Name(Required) First Last Email Address(Required) Phone Number(Required)Date of Birth(Required) Month Day Year Office Location:(Required)Select LocationAlexandria ClinicAndover ClinicAnkeny ClinicAppleton ClinicApple Valley ClinicBaxter/Brainerd ClinicBemidji ClinicBig Lake ClinicBlaine ClinicBloomington ClinicCambridge ClinicCedar Rapids ClinicChaska ClinicCoon Rapids ClinicCottage Grove ClinicCrystal ClinicDes Moines ClinicDuluth ClinicDuluth Mall ClinicEast Grand Forks ClinicEau Claire ClinicEden Prairie ClinicEdina ClinicFargo ClinicFergus Falls ClinicGreen Bay ClinicGreenfield ClinicHudson Township ClinicHugo ClinicHutchinson North ClinicHutchinson South ClinicIowa City ClinicLa Crosse ClinicLakeville ClinicMadison ClinicMankato ClinicMaple Grove ClinicMaplewood ClinicMendota Heights ClinicMinneapolis ClinicMinnetonka ClinicMoorhead ClinicNew Brighton ClinicNorth Liberty ClinicOshkosh ClinicOtsego ClinicRed Wing ClinicRochester South ClinicRochester North ClinicRoseville ClinicSavage ClinicSt. Cloud ClinicSt. Louis Park ClinicStillwater ClinicUnknownWest Des Moines ClinicWillmar ClinicWoodbury ClinicDocument Regarding:(Required)Select OptionIncoming RecordsForm(s) for ProviderGuardianship or Court DocumentsBilling/Insurance DocumentsOtherComments About Document(s) Uploaded:(Required)Upload Document(s)(Required) Drop files here or Select files Accepted file types: 7z, arj, bmp, csv, deb, doc, docx, eml, emlx, gz, jpg, jpeg, key, log, msg, odp, odt, ods, pdf, pkg, pps, ppt, pptx, rar, rpm, rtf, tar, tif, tiff, txt, wpd, xls, xlsm, xlsx, xml, zip, Max. file size: 20 MB, Max. files: 50. ***NOTE: Click on the red X to remove the file.PhoneThis field is for validation purposes and should be left unchanged.
