PATIENT INFORMATION: _______________________________________  DATE FILLED OUT:  _________

Legal Name: __________________________________________________  Phone: (_____) ___________
                       Last                          First                             Middle

Home Address: ________________________________________________________ DOB: ___/____/___
                         Number/Street                          City                      State     Zip

Local Address: __________________________________________________________ Age ___  M  or  F
                         Number/Street                          City                      State     Zip

May we leave a medical message on your answer machine: ____Yes ____ No

SS # : _____-_____-______ Driver's Lic. # _________________ Marital Status:  S  M  D  W  SEP  Partner

Employer: ________________________________________ Phone: (___) _________________________

Address: _________________________________________ Occupation: __________________________

Nearest Friend or Relative: ________________________________ Relationship: ____________________
                                           (not living with you)

Spouse/Significant Other/Guardian's Name: _______________________________ SS # ____-____-____

Employer: __________________________________Phone # ________________ DOB: ____/____/_____

Address: ______________________________________________________________________________
                  Street/Number                                     City                                            State         Zip

PRIMARY INSURANCE CARRIED BY PATIENT              SECONDARY INSURANCE INFORMATION

Insurance Co. Name: ________________________   Insurance Co. Name __________________________

Billing Address: ____________________________    Billing Address ______________________________

_________________________________________    ___________________________________________

Group or Policy #: __________________________    Group or Policy #: ____________________________

Cert. Or Member #: __________________________   Cert. Or Member #: ___________________________

Name of Insured:____________________________  Name of Insured:_____________________________

ASSIGNMENT OF BENEFIT

I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled,
private insurance, and any other health plan to DESERT PRIMARY CARE MEDICAL ASSOCIATES.

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be
considered as valid as an original. I understand that I am financially responsible for all charges, whether or
not paid by said insurance. I hereby authorize said assignee to release all information to secure the payment.


SIGNED:___________________________________________________     DATE: ___________________
                 Parent or Guardian (if Minor)