New Patient Form

Demographics

Title First Last MI Suffix Nickname Dr.

Address:
City:		State/ZipCode	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY TX

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Fedders, Kara Dr. Kelley, Carol Dr. Boisse, Chris Dr. Bauer, Ryan Dr. Visentine, Kelly	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Dr.

Address

City	State	ZipCode
	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY TX

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP Aetna American Family Insurance American Republic Insurance Company Americo Financial Life & Annuity Insurance Co. AMERIPLAN Anthem BCBS Arizona Pipe Trades Health and Welfare Trust Fund Atmel/Delta Health-BCBS AULTCARE Availity Avesis Banker's Life Bankers Fidelity Blue Cross Blue Shield Blue Cross Blue Shield Federal Employees Bright Health CENTRAL STATE INDEMNITY Central States Indemnity Co. of Omaha CENTURY HEALTHCARE CF&I Retirees VEBA Champ VA Change Healthcare Checkway CHP PLUS Cigna Medical Cigna Vision OON Cigna Vision West CMI CNIC Health Solutions CO Carpenters Trust Fund Cofinity Colonial Penn Life Colorado Access Colorado Choice Health Plans Combined Insurance Co. of America Compass Rose Health Care-Med Supp Constitution Life Core Source Cover My Meds Davis Vision Electronic Commerce Healthcare Organization Emblem Health EVEREST EXTRA EyeCarePro FEP Blue Vision FIRST HEALTH First Look/Always Vision Plan - Always Vision FMH CoreSource Freedom Life Insurance Company of America GEHA Gerber Life GHI Gift Certificate Golden Rule Health & Wellfare Benefits/Goodwill Employees Health Net HealthScope HealthSmart Benefit Solutions Inc Heritage Humana Medical INDEPENDENCE AMERICAN Instamed Joint Council LHI LOYAL AMERICAN Lunovus Mail Handlers MHBP MANHATTAN LIFE INSURANCE COMPANY Mayo Clinic Health Solutions Medi-Share Medica MEDICAID Medicaid-Medicare supplement only Medical Network Medicare of Colorado Medico Meritain Health OON MES Vision Metlife Vision MHPB MOAA Mutual of Omaha National Vision Administrators Network Office Ally Omaha Insurance Company Opticare of Utah Optum Health Financial Orange Ulster School Districts Oxford Life Insurance Park Care Plus/ Regional Care Inc ParX Patient Reimbursement payspan PaySpan Payments PHCS Multiplan Physicians Mutual Primera BCBS of WA QualChoice Railroad Medicare Reserve National Rocky Mountain Health Plans Rocky Mountain Pace Secure Horizons Sentinel Significa/Goodwill Employees Smart OD Spectera Standard Life and Health State Farm State Mutual Insurance Company Superior Vision Trans Choice Plus TransAmerica Tricare 4 Life TRICARE WEST/ Health Net Federal Services LLC TriZetto TSYS UHC-Evercare UMWA H&R Funds UNITED AMERICAN United Healthcare United Healthcare/UMR USAA VA Through TRIWEST Veterans Health Choice Program- VACAA Vision Service Plan West Side Cares Workman's Comp
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None AARP Aetna American Family Insurance American Republic Insurance Company Americo Financial Life & Annuity Insurance Co. AMERIPLAN Anthem BCBS Arizona Pipe Trades Health and Welfare Trust Fund Atmel/Delta Health-BCBS AULTCARE Availity Avesis Banker's Life Bankers Fidelity Blue Cross Blue Shield Blue Cross Blue Shield Federal Employees Bright Health CENTRAL STATE INDEMNITY Central States Indemnity Co. of Omaha CENTURY HEALTHCARE CF&I Retirees VEBA Champ VA Change Healthcare Checkway CHP PLUS Cigna Medical Cigna Vision OON Cigna Vision West CMI CNIC Health Solutions CO Carpenters Trust Fund Cofinity Colonial Penn Life Colorado Access Colorado Choice Health Plans Combined Insurance Co. of America Compass Rose Health Care-Med Supp Constitution Life Core Source Cover My Meds Davis Vision Electronic Commerce Healthcare Organization Emblem Health EVEREST EXTRA EyeCarePro FEP Blue Vision FIRST HEALTH First Look/Always Vision Plan - Always Vision FMH CoreSource Freedom Life Insurance Company of America GEHA Gerber Life GHI Gift Certificate Golden Rule Health & Wellfare Benefits/Goodwill Employees Health Net HealthScope HealthSmart Benefit Solutions Inc Heritage Humana Medical INDEPENDENCE AMERICAN Instamed Joint Council LHI LOYAL AMERICAN Lunovus Mail Handlers MHBP MANHATTAN LIFE INSURANCE COMPANY Mayo Clinic Health Solutions Medi-Share Medica MEDICAID Medicaid-Medicare supplement only Medical Network Medicare of Colorado Medico Meritain Health OON MES Vision Metlife Vision MHPB MOAA Mutual of Omaha National Vision Administrators Network Office Ally Omaha Insurance Company Opticare of Utah Optum Health Financial Orange Ulster School Districts Oxford Life Insurance Park Care Plus/ Regional Care Inc ParX Patient Reimbursement payspan PaySpan Payments PHCS Multiplan Physicians Mutual Primera BCBS of WA QualChoice Railroad Medicare Reserve National Rocky Mountain Health Plans Rocky Mountain Pace Secure Horizons Sentinel Significa/Goodwill Employees Smart OD Spectera Standard Life and Health State Farm State Mutual Insurance Company Superior Vision Trans Choice Plus TransAmerica Tricare 4 Life TRICARE WEST/ Health Net Federal Services LLC TriZetto TSYS UHC-Evercare UMWA H&R Funds UNITED AMERICAN United Healthcare United Healthcare/UMR USAA VA Through TRIWEST Veterans Health Choice Program- VACAA Vision Service Plan West Side Cares Workman's Comp
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary

Insurance Information

Insurance Name:	None AARP Aetna American Family Insurance American Republic Insurance Company Americo Financial Life & Annuity Insurance Co. AMERIPLAN Anthem BCBS Arizona Pipe Trades Health and Welfare Trust Fund Atmel/Delta Health-BCBS AULTCARE Availity Avesis Banker's Life Bankers Fidelity Blue Cross Blue Shield Blue Cross Blue Shield Federal Employees Bright Health CENTRAL STATE INDEMNITY Central States Indemnity Co. of Omaha CENTURY HEALTHCARE CF&I Retirees VEBA Champ VA Change Healthcare Checkway CHP PLUS Cigna Medical Cigna Vision OON Cigna Vision West CMI CNIC Health Solutions CO Carpenters Trust Fund Cofinity Colonial Penn Life Colorado Access Colorado Choice Health Plans Combined Insurance Co. of America Compass Rose Health Care-Med Supp Constitution Life Core Source Cover My Meds Davis Vision Electronic Commerce Healthcare Organization Emblem Health EVEREST EXTRA EyeCarePro FEP Blue Vision FIRST HEALTH First Look/Always Vision Plan - Always Vision FMH CoreSource Freedom Life Insurance Company of America GEHA Gerber Life GHI Gift Certificate Golden Rule Health & Wellfare Benefits/Goodwill Employees Health Net HealthScope HealthSmart Benefit Solutions Inc Heritage Humana Medical INDEPENDENCE AMERICAN Instamed Joint Council LHI LOYAL AMERICAN Lunovus Mail Handlers MHBP MANHATTAN LIFE INSURANCE COMPANY Mayo Clinic Health Solutions Medi-Share Medica MEDICAID Medicaid-Medicare supplement only Medical Network Medicare of Colorado Medico Meritain Health OON MES Vision Metlife Vision MHPB MOAA Mutual of Omaha National Vision Administrators Network Office Ally Omaha Insurance Company Opticare of Utah Optum Health Financial Orange Ulster School Districts Oxford Life Insurance Park Care Plus/ Regional Care Inc ParX Patient Reimbursement payspan PaySpan Payments PHCS Multiplan Physicians Mutual Primera BCBS of WA QualChoice Railroad Medicare Reserve National Rocky Mountain Health Plans Rocky Mountain Pace Secure Horizons Sentinel Significa/Goodwill Employees Smart OD Spectera Standard Life and Health State Farm State Mutual Insurance Company Superior Vision Trans Choice Plus TransAmerica Tricare 4 Life TRICARE WEST/ Health Net Federal Services LLC TriZetto TSYS UHC-Evercare UMWA H&R Funds UNITED AMERICAN United Healthcare United Healthcare/UMR USAA VA Through TRIWEST Veterans Health Choice Program- VACAA Vision Service Plan West Side Cares Workman's Comp
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

What is the reason for your visit?

Lost glasses Blurry Vision Irritation Swollen Bloodshot Eye strain Renew Rx Wants to try contacts

Do you feel your eyes are changing? (if yes, please explain)

No Yes

Do you have dry eyes or allergies?

No Yes

When was your last eye exam?

How did you hear about us?

Unknown Insurance Friend/Family Website/Internet Yellow Pages Walk-by/Drive-by

Who was your last eye doctor?

Occupation / Employer:

Hobbies:

How many hours a day do you use a computer?

Preferred Language

English

Race

American Indian or Alaska Native Asian black or African American Native Hawaiian or other Pacific Islander white declined

Ethnicity

Declined Hispanic or Latino Not Hispanic or Latino

Do you wear contact lenses?

No Yes

If no, are you interested in contact lenses?

Yes No

If yes, what type of contacts do you wear?

Daily Wear Extended Wear Soft Disposable Hard Gas Permeable Astigmatism or Toric Bifocal Monovision Mutlifocal

What brand of contacts do you wear?

Air Optix Aqua Air Optix Astigmatism Air Optix Night and Day Focus Dailies Soflens Acuvue Advance Acuvue Oasys Biofinity Other

How often do you replace your contacts?

Monthly Daily Every two weeks Yearly

What brand of solution do you use?

Clear Care OptiFree Pure Moist Bio True Revitalens Boston Original Boston Simplus Renu Generic

How long have your contacts been on your eyes?

Do you have any complaints about your current contacts?

Primary Care Physician:

Telephone #:

Fax #:

Please list any surgeries you have had:

Please list any ocular surgeries you have had

List any medications you are taking:

Are you allergic to any medications? (if yes, please list them)

No medicationsno known medical allergiesYes No

Have you ever been diagnosed with any of the following?

smoking status

not smoker former smoker smoker

discuss cessasion

yes no

Has anyone in your family ever been diagnosed with any of the following? (if so please state their relationship to you) yes no
Cataracts Macular Degeneration GlaucomaTurned Eye High Blood PressureDiabetes NOTES/SOCIAL HISTORY

Review of Systems

Do you use tobacco products?

never smoker previous smoker smoker

Type:

Amount:

How Long?

Do you drink alcohol?

Type:

Amount:

How Long?

Do you use illegal drugs?

Type:

Amount:

How Long?

GonorrheaHepatitisHIV Syphilis

GENERAL: Fever, weight loss, weight gain, fatigue?

SKIN: growths, rashes, acne

None pimples, warts growths rash

NEUROLOGICAL: Headaches, migraines, seizures

None Tremors Paralysis

ENDORCRINE: Thyroid, Diabetes

None diabetes hypothyroid hyperthoyroid

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat

None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

None Asthma Bronchitis Emphysema COPD

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease

None High BP Surgery Vascular Disease

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

None Diarrhea Constipation Ulcer Acid Reflux

KIDNEY, BLADDER: Kidney Stones, Frequent Urination, Pain

None painful urination frequent urination impotence yellow jaundice

MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury

None joint pain stiffness swelling cramps arthritis

BLOOD/LYMPH: Anemia, cholesterol, bleeding problems

None bleeding cholestrolemia anemia

ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus

None sneezing swelling redness itching hives lupus

PSYCHIATRIC: Depression, Anxiety, Insomnia

None anxiety depression insomnia

Last Dr Visit:

1 week 1 month 3 months 6 months 1 year 2 years

Reason For Visit:

Check up Annual

Injuries, Surgeries, Hospitalization

Vitamins:

None A E C Zinc Xanten Lutein

Diabetic info:

Controlled?:

yes no

Discussed Smoking Cessation

No Yes

Submit Data / Patient Signatures

ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES

Please click on the blue underlined link below to view the ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES.

View ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES

The law requires that Kara Fedders, OD, P.C. make every effort to inform you of your rights related to your personal health formation. By signing below, I acknowledge that:

I have read or had explained to me prior to any services offered Kara Fedders, OD, P.C.'s Notice of Privacy Practices and agree to continue my care with Kara Fedders, OD, P.C. under said terms.

I was given the opportunity to read Kara Fedders, OD, P.C.'s Notice of Privacy Practices and declined, but wish to continue my care with Kara Fedders, OD, P.C. said terms.

I have read or had explained to me prior to any services offered Kara Fedders, OD, P.C.'s Notice of Privacy Practice and disagree to continue my care with Kara Fedders, OD, P.C. under said terms.

The Notice of Privacy Practices could not be read due to the emergent nature of the care of other reasons describes as:


I HAVE READ AND UNDERTSAND THIS FORM. I AM SIGNING IT VOULUNTARILY.

Patient Signature: Date:

If you are signing as a personal representative of the patient then please indicate your relationship.

Representative Relationship To Patient

SIGNATURE ON FILE FORM

RESPONSIBILITY STATEMENT

Your insurance is a method for you to receive reimbursement for fees you have paid to the optometrist for services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowance or percentages based on your contract with them, not with our office. It is your responsibility to pay in advance for the deductible, coinsurance, or any other balances not paid for by your insurance. We will assist you in receiving your reimbursement as much as possible, but you are responsible in advance for your bill.

FINANCIAL RESPONSIBILITY

By signing this statement you agree to be financially responsible for all charges.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I authorize any holder of medical information about me to release Heath Care Financing Administration and its agents any information needed to determine benefits or the benefits payable to related services. This assignment will remain in effect until it is revoked in writing. A photocopy of this assignment is considered to be as valid as the original.

Patient Signature: Date: