To be completed by patient
	Patient Name___________________________________________________________ Address______________________________________________________________ City___________________________  State______________  Zip________________ Employer Name_____________________Health Plan___________________________

To be completed and mailed by physician

___ Yes, I would like information on joining The First Health® Network. Physician Name________________________________________________________ Office Address________________________________________________________ City__________________________  State______________  ZIP________________ Telephone___________________________________________________________ State(s) you practice in:_________________________________________________ Hospitals at which you have admitting privileges: _____________________________________ _____________________________________ Specialty(s):___________________ ____________________________ ____________________________   Physician Signature:___________________________________________________

______________________________ ______________________________ ______________________________ ______________________________

Place Stamp Here

First Health 4141 North Scottsdale Road Suite 220 Scottsdale, AZ 85251