COACHELLA VALLEY VOLUNTEERS IN MEDICINE (CVVIM)NEW PATIENT REGISTRATION FORM

(Please Print)Today’s Date:

/ /Briefly describe the reason for today’s visit:

PATIENT INFORMATION

Last Name: First: Middle:

Birth Date:/ /

Age: Gender:□ Male□ Female□ Trans Female-to-Male□ Trans Male-to-Female□ Gender Non-binaryDo you have a preferred name? _______________________

Street address: City Zip Code:

Preferred Phone:( )

Secondary Phone:( )

Marital Status:□ Single □ Married□ Divorced□ Domestic Partner□ Other

Email Address: @Are you: □ USA Citizen □ Mexican Citizen □ Other

Social Security Number □ NO □ YES# / /

Person to contact in case of emergency:

Name: _______________________________________

Relationship: __________________________________

Telephone Number: ____________________________

Race/Ethnicity:□ Hispanic □ Caucasian/White □ Other□ African American ___________________□ Native American/Alaskan□ Other Pacific Islander□ Asian American

ADDITIONAL INFORMATION

Have you been to the Emergency Room as a patient recently?

□ YES □ NO

If yes, which hospital’s Emergency Room?□ Eisenhower Medical Center (Rancho Mirage)□ JFK Memorial Hospital (Indio)□ Desert Regional Medical Center (Palm Springs)

If YES, when did you visit the ER?

If YES, what were you treated for?

Education:□ High School Diploma/ GED□ Grades K-6 □ College□ Grades 7-12 □ No School

How many visits to the Emergency Room have you made in the last year?

Mode of Transportation to get to CVVIM: □ Walk □ Car □ Bus □ Other __________________

EMPLOYMENT and HEALH CARE COVERAGE STATUS

Revised 10/14

Are you currently employed?

□ YES □ NO

Employer Name: Does your employer offer health insurance? □ YES □ NO

Class of Work:□ Construction□ Agriculture / Farmer□ Landscaper / Gardener□ Housekeeper□ Hotel / Motel□ Maintenance / Janitor□ Restaurant / Food Services□ Healthcare / Homecare□ Other: __________________

Employment Status:□ Unemployed□ Employed – Part time□ Employed – Full time□ Seasonal□ Retired□ Disabled□ Self-employed□ Student

Have you ever applied for Health Care with:Medi-Cal

□ YES □ NOMedically Indigent Services Program (MISP)

□ YES □ NORiverside County Health Program

□ YES □ NOPrivate Insurance/Covered California

□ YES □ NO

Name of city you work in: Do you have more than one employer/job? □ YES □ NO

COACHELLA VALLEY VOLUNTEERS IN MEDICINE (CVVIM)NEW PATIENT ELIGIBILITY FORM

(Please Print)

Today’s Date:/ /

Patient’s Name:Last: First: Middle:

HOUSEHOLD SIZE AND INCOME VERIFICATION

Number of People in Your Household

Annual Income for all Persons in the Household (200% of 2014

FPL)

1 $0 to $17,505

2 $31,460 (or less)

3 $39,580 (or less)

4 $47,700 (or less)

5 $55,820 (or less)

6 $63,940 (or less)

7 $72,060 (or less)

Revised 10/14

8 or more $80,180 (or less)

Patient’s Household Size: ______ Patient’s Household Annual Income: $ ___________________________

Proof of Income: □ Paycheck(s) (make copy for file) □ Previous Year’s Tax Return(s) (make copy for file)

□ W-2 (s) (make copy for file) □ Other? ______________________________________________________________________

COACHELLA VALLEY RESIDENCY VERIFICATION

Proof of Residency in the Coachella Valley (dated within the past three months):

□ Gas Bill (make copy for file) □ Electric Bill (make copy for file) □ Property Tax Statement (make copy for file) □ Telephone Bill (make copy for file) □ Pay Stub (make copy for file) □ Other Bill or Statement (make copy for file)

□ Homeless (no proof required)

Printed Name of CVVIM Volunteer/Staff that reviewed this form: _________________________________________

Revised 10/14