PrimeTime Membership Application

Name ______________________________________________

Address ____________________________________________

City ______________________ Zip ___________________

Phone ____________________ Phone _________________

Email ____________________

Marital Status: Married Spouses Name: _____________)
  Single Widowed
 

Your Physician (s) ____________________________

Have you ever received care at DMH? Yes No

I hereby make application for membership in PrimeTime and enclose my $10 one-time membership fee, payable to
"Decatur Memorial Hospital – PrimeTime." I anticipate receipt of my PrimeTime membership card in two weeks at the address provided above.

Signature __________________ Date _________

Print and mail along with your $10 membership fee to:
DMH PrimeTime, 2300 N. Edward St., Decatur, IL 62526