InSURANCE REIMBURSEMENT DOCUMENTATION (IRD) SEND-OUT FORM Clinician Name(Required) First Last Clinician Gmail Enter Email Confirm Email Please use your Change, Inc. Gmail (NOT your @changeincorporated.org address)Client Name(Required) First Last Client Email(Required) Enter Email Confirm Email Date of Initial IRD Request(Required) MM slash DD slash YYYY Today's Date(Required) MM slash DD slash YYYY Upload IRD PDF here. Multiple files are allowed if necessary.(Required) Drop files here or Select files Max. file size: 32 MB. Attestation regarding Google Drive Upload(Required) I have uploaded the above attached PDF to the appropriate client file on the Change, Inc. Google DriveCAPTCHA Δ
