tist First 8, Last Name p,.ofti, do _sraroacliaro IDS Existing Patient? &?es °No Existing Patiegt? /0)..s ,. No Prim* Care Physician' Physician First & Last 1- 7;6 Yro o /au Haar Olth.el €.41 I -1 .39-49/ Declining coverage due to existence of other coverage: Spouse's Employers Plan Individual Plan

efforts to collect and report the name, mailing address, occupation and employer of individuals whose contributions exceed $200 in a calendar year. First & Last Name: Address: City/State/Zip: Employer: Occupation: Work Phone: Work Fax: Home Phone: Email: Federal law prohibits foreign nationals, excep