Patient Registration | Volunteers In Medicine

PATIENT INFORMATION

Today's Date *

Why do you need to see a doctor? *

Name *

First

Last

Do you have a preferred name?

Email *

Email

Confirm Email

Birth Date *

Street Address

Address Line 1

Address Line 2

City

State

Zip Code

Is your Street Address the same as your Mailing Address?

Yes
No

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Enter your mailing address (if different from your Street Address)

Phone (Primary Phone) *

Is this a CELL phone? *

Phone (Secondary Phone)

Gender *

Marital Status *

Photo ID (check one) *

Driver's License
State ID
Passport
Native Tribal Card

Proof of Residency *

Race | Ethnicity *

Other Race | Ethnicity

Primary Language Spoken *

Primary Language Read *

Who do we contact in case of an EMERGENCY? *

First

Last

Phone (Emergency Contact) *

EMPLOYMENT INFORMATION

Are you currently employed? *

Yes
No

In what city do you work?

Class of work (select one): *

Employment Status (select one): *

Have you been to the Emergency Room as a patient within the past 6 months? *

Yes
No

If YES, how many visits to the Emergency Room have you made in the past year? *

If YES, which hospital's Emergency Room did you visit? (select one) *

Eisenhower Medical Center (Rancho Mirage)
JFK memorial Hospital (Indio)
Desert Regional Medical Center (Palm Springs)
Riverside County Regional Medical Center (Moreno Valley)
I have not been to the Emergency Room as a patient within the past 6 months

Who referred you to CVVIM? *

How did you get to CVVIM? (select one): *

HOUSEHOLD SIZE & INCOME VERIFICATION

Number of people in your (PATIENT's) Household | Annual Income Requirements (select one):

1: $30,300 Family income cannot exceed this amount.

2: $42,300 Family income cannot exceed this amount.

3: $53,300 Family income cannot exceed this amount.

4: $64,300 Family income cannot exceed this amount.

5: $75,300 Family income cannot exceed this amount.

6: $86,300 Family income cannot exceed this amount.

7: $97,300 Family income cannot exceed this amount.

8: 108,300 Family income cannot exceed this amount.

9+: Add $11,000 for each additional person.

Proof of Income (select one): *

Are you paid in cash? *

Yes
No

ADDITIONAL INFORMATION

Education (select one): *

Have you ever applied for Health Care with Medi-Cal? *

Yes
No

If YES, are you currently covered by Medi-Cal? *

Yes
No

If YES, was it for an emergency only? *

Yes
No

Have you ever applied for Health Care with Medically Indigent Services Program (MISP)? *

Yes
No

If YES, are you currently covered by Medically Indigent Services Program (MISP)? *

Yes
No

Have you ever applied for Health Care with Covered California? *

Yes
No

If YES, are you currently covered by Covered California? *

Yes
No

Have you ever applied for Health Care with a Private Insurance company? *

Yes
No

If YES, are you currently covered by a Private Insurance company? *

Yes
No

Does your employer offer health insurance? *

Yes
No

If YES, are you currently covered? *

Yes
No

Are you a United States Veteran? *

Yes
No

VERIFICATION

Please review your form to be sure all questions have been answered.
Click SUBMIT to send your form.

Name of the person who completed application: *

First

Last

DO NOT COMPLETE THIS SECTION. CVVIM STAFF OR VOLUNTEER ONLY.

Name

First

Last