Patient Intake Form 

Please fill out the form to expedite service.


Print and fax a printable version to (562)808-2203 


Email :



You must call (562) 808-2273 to verify that your form has been received by fax or email 

Insurance Providers

Most Common Workers’ Comp Insurance Carriers:


  • AIG

  • Corvell

  • Farmer’s

  • ESIS

  • Health First

  • Octagon Risk

  • Sedwick

  • State Farm

  • State Fund

  • Traveler’s

  • Tristar





  • Aetna

  • Blue Cross

  • Blue Shield

  • Cigna

  • Health Net

  • MediCal

  • MediCare

  • Molina

  • Pacificare

  • TriWest

  • United Health Care




Call To Verify Your HMO Plan.
Please contact us if your insurance is not listed.

In House Care Option Plan 

Dusk to Dawn offers an In-House Health Care Option Plan that is available for any patient that wants to see our physicians. The following is a list of the services under our In-House Health Care Option Plan. Listed below is a sample standard contract for the Health Care Option Plan. Should you have any questions, please feel free to contact us.


Procedures Covered:




  • Accucheck

  • Cardiac Enzymes

  • CPK

  • Myoglobin

  • Troponin

  • Urinalysis

  • Urine Pregnancy Test

  • Urine Drug Test

  • Venipuncture





  • Breathing Treatment

  • Dressing Change

  • Fracture Reduction

  • Immunizations

  • Incision & Drainage of Abscess

  • Pelvic Exams

  • Reduction of Small Bone Dislocation

  • Repair of Nailbed

  • Splinting and Casting

  • Suture & Suture Removal

  • Ultrasound