New Patient Form
Demographics
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Miss
Address:
City:
State/ZipCode
NY
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
Single
Married
Separated
Divorced
Widowed
Unknown
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. Schiff, Steven
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Miss
Address
City
State
ZipCode
NY
Home Phone:
Work Phone:
Vision Plan
Insurance Information
Insurance Name:
None
Aetna
Block Vision
Blue Cross/Blue Shield
Cigna
Comprehensive
Davis Vision
Empire Bcbs
Eyemed
GHI (Emblem)
Guardian
HIP (Emblem)
March Vision / Eyesynergy
Medicare
New Insurance
NVA
Optum Health (Spectera)
Oxford (UNH)
Tricare
United Health Care (Empire Plan)
Vision Screening
VSP
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:
Primary
Insurance Information
Insurance Name:
None
Aetna
Block Vision
Blue Cross/Blue Shield
Cigna
Comprehensive
Davis Vision
Empire Bcbs
Eyemed
GHI (Emblem)
Guardian
HIP (Emblem)
March Vision / Eyesynergy
Medicare
New Insurance
NVA
Optum Health (Spectera)
Oxford (UNH)
Tricare
United Health Care (Empire Plan)
Vision Screening
VSP
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
Aetna
Block Vision
Blue Cross/Blue Shield
Cigna
Comprehensive
Davis Vision
Empire Bcbs
Eyemed
GHI (Emblem)
Guardian
HIP (Emblem)
March Vision / Eyesynergy
Medicare
New Insurance
NVA
Optum Health (Spectera)
Oxford (UNH)
Tricare
United Health Care (Empire Plan)
Vision Screening
VSP
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
Aetna
Block Vision
Blue Cross/Blue Shield
Cigna
Comprehensive
Davis Vision
Empire Bcbs
Eyemed
GHI (Emblem)
Guardian
HIP (Emblem)
March Vision / Eyesynergy
Medicare
New Insurance
NVA
Optum Health (Spectera)
Oxford (UNH)
Tricare
United Health Care (Empire Plan)
Vision Screening
VSP
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:
Submit Data
After Completing All Forms Submit Data on Final Tab