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PATIENT REGISTRATION
Please enable JavaScript in your browser to complete this form.
VIM is NOT an Urgent Care Clinic.
If you have a
MEDICAL
EMERGENCY
, CALL 911
or visit an Emergency facility in your area.
We provide Primary Medical Care only. We do not provide Dental Services at this time.
PATIENT INFORMATION
The terms of our Eligibility Requirements do not permit us to accept applicants that reside outside of the Coachella Valley.
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
*
Do you have a Social Security number?
Yes
No
Social Security Number
*
Street Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is your Street Address the same as your Mailing Address?
Yes
No
Mailing Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Enter your mailing address (if different from your Street Address)
Phone (Primary Phone)
*
Is this a CELL phone?
*
Yes
No
Phone (Secondary Phone)
Gender
*
Male
Male
Female
Transgender
Marital Status
*
Single
Single
Married
Divorced
Domestic Partner
Photo ID (check one)
*
Driver's License
State ID
Passport
Native Tribal Card
Are you a U.S. Citizen? (Undocumented Residents are eligible for service)
*
Yes
No
Proof of Residency
*
Gas Bill
Electric Bill
Telephone Bill
Property Tax Statement
Other Utility Bill w/Home Address
Homeless (No Proof Required)
Race | Ethnicity
*
African American
Asian American
White (Caucasian)
Hispanic
Latino
Mexican
Native American
Alaskan
Other
Other Race | Ethnicity
Primary Language Spoken
*
English
Spanish
Chinese/Cantonese/Mandarin
Filipino
Vietnamese
French
Primary Language Read
*
English
Spanish
Chinese/Cantonese/Mandarin
Filipino
Vietnamese
French
Who do we contact in case of an EMERGENCY?
*
First
Last
Phone (Emergency Contact)
*
EMPLOYMENT INFORMATION
Are you currently employed?
*
Yes
No
Employer Name
In what city do you work?
Class of work (select one):
*
Construction
Agriculture | Farmer
Landscaper | Gardner
Hotel | Motel
Maintenance | Janitor
Restaurant | Food Service
Healthcare | Homecare
Other
Employment Status (select one):
*
Unemployed
Employed - Part Time
Employed - Full Time
Seasonal
Retired
Disabled
Self-Employed
Student
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?
*
1
2
3
4
5
6
7
8
9
10
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):
*
Bus
Car
Friend or Family Member
Taxi
Walk
Other
HOUSEHOLD SIZE & INCOME VERIFICATION
Number of people in your (PATIENT's) Household | Annual Income Requirements (select one):
1
2
3
4
5
6
7
8
9+
1: $30,120 Family income cannot exceed this amount.
2: $40,880 Family income cannot exceed this amount.
3: $51,640 Family income cannot exceed this amount.
4: $62,400 Family income cannot exceed this amount.
5: $73,160 Family income cannot exceed this amount.
6: $83,920 Family income cannot exceed this amount.
7: $94,680 Family income cannot exceed this amount.
8: 105,440 Family income cannot exceed this amount.
9+: Add $10,760 for each additional person.
Proof of Income (select one):
*
Paycheck(s). Please bring ORIGINAL paycheck stubs. We will make a copy for our files.
Tax Return(s). Please bring previous year's Tax Returns. We will make a copy for our files.
W2's. Please bring your W2's. We will make a copy for our files.
Other. Please bring other proof of income. We will make a copy for our files.
Homeless. No proof of income required.
Are you paid in cash?
*
Yes
No
ADDITIONAL INFORMATION
Education (select one):
*
High School Diploma | GED
High School Diploma | GED
Grades K-6
No School
Some College
College Graduate
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
SUBMIT
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