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Demographics
Patient Information
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First
Last
MI
Suffix
Nickname
Pronoun
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
he/him/his
she/her/hers
they/them/theirs
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City:
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TN
KY
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Other Phone:
Alerts:
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Preferred Contact Method:
Text Message
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Home Phone
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SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
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Polygamous
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Employer / School Name
Misc/Guardian
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Billing Information
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Copy Address From Above
Address
City
State
ZipCode
TN
KY
Home Phone:
Work Phone:
Primary-Medical
Insurance Information
Insurance Name:
None
AARP
AARP Discount Program
Accident Fund
Ace American Ins Co
Acordia Senior of the South
ACS/GlobalCare, Inc
Administrative Concepts
Admiral Life Insurance Company of America
Advantra Freedom
Aetna
Aetna Health
Aetna Life Advantage Medicare Program
Aetna One Vision Discount
AIG Domestic Claim
Alicare
Aliera Care
All Savers
Allied Benefit Systems, Inc
Alpha Review Corporation
AlwaysCare Vision Claims
Ambetter (We are not in network)
AmComp Claims Department
American Business Coalition
American Continental Ins Co
American Health Group
American Heritage LIfe Ins Co
American Medical Security
American Pioneer Life
American Republic Ins Co
American Republic Insurance Co.
Americhoice
Americo Financial Life
Amerigroup
AmeriHealth Administrators
Ameritas
Amerivantage
Anthem Blue Cross Blue Shield
APWU Health Plan
Arnold Fabricating & Machine
Assurant Health
Assurant Health Attn: Claims
AssureCare of Illinois
Attorney pmt for medical records
Auto-Owners Insurance
Avesis
AWA PMT
Bankers Fidelity
Bankers Life & Casualty
Belisle Machine
Benefit Consultants, Inc
Benefit Planners
Benefits Assistance Corp.
Benefits Department
Benesight
Benton County Electric System
Benton County Ministerial Alliance
Benton County Sheriff's Department
Block Vision/Superior Vision
Blue Advantage
Blue Care
Blue Care Plus
Blue Cross Blue Shield of Tennessee
Blue Perks Discount
Bluegrass Family Health Network
Boilermakers National Fund-----BNF
Boon Chapman Benefit Administrators
Broadspire Services
Brookshire Hathaway
CAHABA GBA PART B Medicare
Camden Machine Works
Capitol Administrators of the Southeast
Carey & Counseling Attn: A/P
CBA
Central Benefits
Central State Health & Life Co.
Central States Southeast and Southwest Areas
Central United Life
Century Healthcare, LLC
CHAMPVA
Chartis
Cherokee Insurance Company
Cigna Government Services
Cigna Health Care
Cigna Health Spring/Medicare
Cigna Healthcare
Cigna International
Cigna Medical (Boilermakers)
Cigna PPO
Cigna Total Choice Medicare/American Retirement
Cigna Vision, Claims Dept
CignaHealthCare
City of Camden
Claims Office
Claims Processing Contractor
Closing The Gap
Coast to Coast Discount Plan
Cole Vision 10% Discount Plan
Colonial Penn
Combined
Community Eye Care
Community Health Alliance
Community Service Network of West TN
Companion Life
Compbenefits
Concentra Tampa Technology Center
Connecticut General Life Ins. Co
Conseco
Consumers Insurance
Continental General Insurance Company
Continental Life Ins. Co.
Cornerstone - Attn: Candace
Country Club & Grill
Country Life Insurance Company
Covenant Administrators, Inc.
Coventry Health Care
Cover Kids-BCBS
Cover Kids-EyeQuest
Cover Kids-March
Crossamerica Health Plans
CSI
Dana
Davis Vision
Davis Vision Discount Plan
Days & Zimmerman - NPS Workers Comp
Department of Veterans Affairs
Deseret Mutual
Discount Plan
Douglas County Separate Juvenile Court
Dunn and Associates
EBC Mid America
EBMS
ECPA Claims Administration
Equipoint
Equitable Life & Casualty
Essilor
Everest
Eye Med Vision Care
Eyeconic-VSP
Eyemed Discount Plan
EyeQuest
Family Life Ins Co
Farm Bureau Agency
Farm Bureau Health Plans
Federated Insurance
FEP Vision Discount
First Comp
First Health
First Script DME Plus Claims Dept
Fox Everett
Frank Lill & Son Inc.
Gallagher Bassett Service, Inc.
Gallagher Bassett Services, Inc.
GEHA
Gerber Life Insurance
GHI
Golden Rule Insurance
GPM Life
Great-West Healthcare
Great American Life Ins Co
Guarantee Trust Life
Guardian
Guardian Insurance-Vision Processing Unit
Gulf Guaranty Claims
GWH Cigna
Hamilton Ryker Attn: Ladona
Hartford Life
Health Cost Companies
Health Partners
Health Plan
HealthComp - NovaNet, Inc
HealthScope Benefits, Inc
Healthsmart
HealthSpring Medicare
Heartland National
HMA Insurance
HMA, LLC
Hughes & Coleman Injury Lawyers
Humana
Humana Vision Discount
Humana Gold Choice
Humphreys County Sheriff
IAC
Infant See
Insurance Benefits System Administrators c/o Zelis
John Alden Life Insurance Company
Jones Plastic Workers Comp
Kaiser Foundation Health Claims Dept.
Key Benefit Administrators, Inc.
KHS-Humana
Lensferry
LHI - Attn Accounts Payable
Liberty Mutual
Life Care Centers of America
Lincoln Heritage Life Ins
Lions Club
LMI
Loomis
Loyal American
Lumbermans Underwriting Alliance
Lumico
Magpro
Mail Handlers Benefit Plan
ManageMED
Manhattan Life Ins Co
March Vision
Marsh Advantage America
MedCo Health Solutions, Inc
Medi-Share
Medicaid
Medical Mutual
Mediplus
Meritain Health Minneapolis
Met Life
Mid Central Operating Engineers
Mid South Carpenters Regional Council
Midway Materials
Midwest National Life Insurance
Midwest Operating Engineers Welfare Fund
Military Benefit Association
MMS
Monumental Life Insurance Co
Motorola
Mutual of Omaha
Mutual of Omaha Manufacturing Companies
N E I H B P
NALC Health Benefit Plan
Natchez Trace Youth Academy
National Asbestos Workers Fund
National Care Network
National States Insurance Company
Nationwide Life Insurance
Nationwide Specialty Health Claims
NECA/IBEW Family Medical Care Plan
New Era Life Insurance Co
New Insurance
NGS American, Inc
Nippon Life Ins Co of America
Norman Marine
North America Industries, Inc.
North American Administration L.P.
Northwest Administrative Office
Northwest Tennessee Headstart
Nova Healthcare Administrators, Inc.
Nova Net
NVA
ODS-OHP Medical Claims
Operating Engineers Health
Operating Engineers Locals Welfare Trust Fund
Pacific Life Annuity
PAI
Palmer Tool, LLC
Palmetto GBA Medicare - Palmetto GBA Medicare
Pan American Benefits Solutions
Pearce Administration
Pennsylvania Life Ins Co
PersonalCare
Philadelphia American Life Ins Co
Physicians Mutual
Plumbers & Pipefitters #572
PML / USA H&W Network
POMCO Group
PPOM
Premier Eye Care
Principal Financial Group
Principal Life Ins
Prudential/AARP Claim Unit
Pyramid Claims
Pyramid Life
QMB
QualChoice of Arkansas, Inc
Railroad Medicare
Renaissance Life
Reserve National Insurance Company
Robins Insurance Agency
Roll Tooling Specialist
Royal Neighbors of America
RSL Specialty Products Administration
Rural Carrier Benefit Plan
Safety Specs Pmt
Secure Horizons
Secure Plus
Sedgwick
Select Benefit Administrators of America
Sentry Insurance Claims Dept.
Shenandoah Life Insurance
Signature Health Alliance
Simple
SISCO - Self Insured Services Co.
Southeast Laborers Health Fund
Southern Benefit Administrators, Inc
Southern Guarantee
Southwest Human Resource Agency
Spectera
Standard Life & Accident
Standard Security Life Ins Co
Star HRG-Galaxy Health Network
Starmark
State Farm Insurance Companies
State of Tennessee
Sterling Investors
Sterling Option I
Summit Claims Center
Superior Vision Plan
Superior Vision Services, Inc
TennCare Select
Tennessee Health Care
Tennessee Health Care Attn: Repricing Dept.
Tennessee Valley Operating Engineers Health Fund
Tennessee Valley Painters Health Fund
THA Solutions Group
Thrivent Financial
TICUA Benefit Consortium c/o Meritain Health
Time Insurance Company
TN Carpenters Regional Council Hlth & Welfare Fund
TN PPO PPA Direct
Transamerica Life Ins Co
Tricare Military Healthcare w/ Humana
TriWest WPS-VAPC3 (do not use 2020)
Trustmark Life Insurance Company
TVA Johnsonville Fossil Plant
U.A. Local Union No. 614
UMR
Unicare
UniCare - The Chandler Group
Unified Group Services
Unimin Corp
Union Pacific Railroad Employees Health Systems
Unison Advantage
United American Ins Co
United Commercial Travelers
United Health Care-Dual Complete
United Health Care-Students
United Health Care Oxford
United Health Care/TX
United Healthcare - Railroad
United Healthcare Community Plan
United Healthcare River Valley
United Healthcare/ UT
United Healthcare/Atlanta
United Insurance Company of America
United Life Insurance Company
United Service Association For Health Care
United Teacher Associates Ins Com
United Way
United World Life Ins Co
UnitedHealthcare-Choice Plus
US Dept of Labor-OWCP
US Health & Life
USA +Claims Service
USA H&W Network
USA MCO
VA Health Net Patient Centered Community Care
Valley West Welding Company
VES Services
Vision Benefits of America
Vision Care Plan
Vision Service Plan
Vision Source
Vocational Rehab
VSP Discount Plan
Wagner Construction
Watkins Associated Industries, Inc.
Wausau Benefits
Waverly Wood
WEBTPA
WellCare
Western United Life
William C Beeler and Company
Willis Corroon Administrative Corp
Windsor Health Plans Claims(WellCare---we do not take medical-vision is Superior)
Woodmen of the World
Workers Compensation
WPS VAPC3 (do not use 2020)
Zurich North America
Zyrec Insurance
Insurance Plan:
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:
Second Med
Insurance Information
Insurance Name:
None
AARP
AARP Discount Program
Accident Fund
Ace American Ins Co
Acordia Senior of the South
ACS/GlobalCare, Inc
Administrative Concepts
Admiral Life Insurance Company of America
Advantra Freedom
Aetna
Aetna Health
Aetna Life Advantage Medicare Program
Aetna One Vision Discount
AIG Domestic Claim
Alicare
Aliera Care
All Savers
Allied Benefit Systems, Inc
Alpha Review Corporation
AlwaysCare Vision Claims
Ambetter (We are not in network)
AmComp Claims Department
American Business Coalition
American Continental Ins Co
American Health Group
American Heritage LIfe Ins Co
American Medical Security
American Pioneer Life
American Republic Ins Co
American Republic Insurance Co.
Americhoice
Americo Financial Life
Amerigroup
AmeriHealth Administrators
Ameritas
Amerivantage
Anthem Blue Cross Blue Shield
APWU Health Plan
Arnold Fabricating & Machine
Assurant Health
Assurant Health Attn: Claims
AssureCare of Illinois
Attorney pmt for medical records
Auto-Owners Insurance
Avesis
AWA PMT
Bankers Fidelity
Bankers Life & Casualty
Belisle Machine
Benefit Consultants, Inc
Benefit Planners
Benefits Assistance Corp.
Benefits Department
Benesight
Benton County Electric System
Benton County Ministerial Alliance
Benton County Sheriff's Department
Block Vision/Superior Vision
Blue Advantage
Blue Care
Blue Care Plus
Blue Cross Blue Shield of Tennessee
Blue Perks Discount
Bluegrass Family Health Network
Boilermakers National Fund-----BNF
Boon Chapman Benefit Administrators
Broadspire Services
Brookshire Hathaway
CAHABA GBA PART B Medicare
Camden Machine Works
Capitol Administrators of the Southeast
Carey & Counseling Attn: A/P
CBA
Central Benefits
Central State Health & Life Co.
Central States Southeast and Southwest Areas
Central United Life
Century Healthcare, LLC
CHAMPVA
Chartis
Cherokee Insurance Company
Cigna Government Services
Cigna Health Care
Cigna Health Spring/Medicare
Cigna Healthcare
Cigna International
Cigna Medical (Boilermakers)
Cigna PPO
Cigna Total Choice Medicare/American Retirement
Cigna Vision, Claims Dept
CignaHealthCare
City of Camden
Claims Office
Claims Processing Contractor
Closing The Gap
Coast to Coast Discount Plan
Cole Vision 10% Discount Plan
Colonial Penn
Combined
Community Eye Care
Community Health Alliance
Community Service Network of West TN
Companion Life
Compbenefits
Concentra Tampa Technology Center
Connecticut General Life Ins. Co
Conseco
Consumers Insurance
Continental General Insurance Company
Continental Life Ins. Co.
Cornerstone - Attn: Candace
Country Club & Grill
Country Life Insurance Company
Covenant Administrators, Inc.
Coventry Health Care
Cover Kids-BCBS
Cover Kids-EyeQuest
Cover Kids-March
Crossamerica Health Plans
CSI
Dana
Davis Vision
Davis Vision Discount Plan
Days & Zimmerman - NPS Workers Comp
Department of Veterans Affairs
Deseret Mutual
Discount Plan
Douglas County Separate Juvenile Court
Dunn and Associates
EBC Mid America
EBMS
ECPA Claims Administration
Equipoint
Equitable Life & Casualty
Essilor
Everest
Eye Med Vision Care
Eyeconic-VSP
Eyemed Discount Plan
EyeQuest
Family Life Ins Co
Farm Bureau Agency
Farm Bureau Health Plans
Federated Insurance
FEP Vision Discount
First Comp
First Health
First Script DME Plus Claims Dept
Fox Everett
Frank Lill & Son Inc.
Gallagher Bassett Service, Inc.
Gallagher Bassett Services, Inc.
GEHA
Gerber Life Insurance
GHI
Golden Rule Insurance
GPM Life
Great-West Healthcare
Great American Life Ins Co
Guarantee Trust Life
Guardian
Guardian Insurance-Vision Processing Unit
Gulf Guaranty Claims
GWH Cigna
Hamilton Ryker Attn: Ladona
Hartford Life
Health Cost Companies
Health Partners
Health Plan
HealthComp - NovaNet, Inc
HealthScope Benefits, Inc
Healthsmart
HealthSpring Medicare
Heartland National
HMA Insurance
HMA, LLC
Hughes & Coleman Injury Lawyers
Humana
Humana Vision Discount
Humana Gold Choice
Humphreys County Sheriff
IAC
Infant See
Insurance Benefits System Administrators c/o Zelis
John Alden Life Insurance Company
Jones Plastic Workers Comp
Kaiser Foundation Health Claims Dept.
Key Benefit Administrators, Inc.
KHS-Humana
Lensferry
LHI - Attn Accounts Payable
Liberty Mutual
Life Care Centers of America
Lincoln Heritage Life Ins
Lions Club
LMI
Loomis
Loyal American
Lumbermans Underwriting Alliance
Lumico
Magpro
Mail Handlers Benefit Plan
ManageMED
Manhattan Life Ins Co
March Vision
Marsh Advantage America
MedCo Health Solutions, Inc
Medi-Share
Medicaid
Medical Mutual
Mediplus
Meritain Health Minneapolis
Met Life
Mid Central Operating Engineers
Mid South Carpenters Regional Council
Midway Materials
Midwest National Life Insurance
Midwest Operating Engineers Welfare Fund
Military Benefit Association
MMS
Monumental Life Insurance Co
Motorola
Mutual of Omaha
Mutual of Omaha Manufacturing Companies
N E I H B P
NALC Health Benefit Plan
Natchez Trace Youth Academy
National Asbestos Workers Fund
National Care Network
National States Insurance Company
Nationwide Life Insurance
Nationwide Specialty Health Claims
NECA/IBEW Family Medical Care Plan
New Era Life Insurance Co
New Insurance
NGS American, Inc
Nippon Life Ins Co of America
Norman Marine
North America Industries, Inc.
North American Administration L.P.
Northwest Administrative Office
Northwest Tennessee Headstart
Nova Healthcare Administrators, Inc.
Nova Net
NVA
ODS-OHP Medical Claims
Operating Engineers Health
Operating Engineers Locals Welfare Trust Fund
Pacific Life Annuity
PAI
Palmer Tool, LLC
Palmetto GBA Medicare - Palmetto GBA Medicare
Pan American Benefits Solutions
Pearce Administration
Pennsylvania Life Ins Co
PersonalCare
Philadelphia American Life Ins Co
Physicians Mutual
Plumbers & Pipefitters #572
PML / USA H&W Network
POMCO Group
PPOM
Premier Eye Care
Principal Financial Group
Principal Life Ins
Prudential/AARP Claim Unit
Pyramid Claims
Pyramid Life
QMB
QualChoice of Arkansas, Inc
Railroad Medicare
Renaissance Life
Reserve National Insurance Company
Robins Insurance Agency
Roll Tooling Specialist
Royal Neighbors of America
RSL Specialty Products Administration
Rural Carrier Benefit Plan
Safety Specs Pmt
Secure Horizons
Secure Plus
Sedgwick
Select Benefit Administrators of America
Sentry Insurance Claims Dept.
Shenandoah Life Insurance
Signature Health Alliance
Simple
SISCO - Self Insured Services Co.
Southeast Laborers Health Fund
Southern Benefit Administrators, Inc
Southern Guarantee
Southwest Human Resource Agency
Spectera
Standard Life & Accident
Standard Security Life Ins Co
Star HRG-Galaxy Health Network
Starmark
State Farm Insurance Companies
State of Tennessee
Sterling Investors
Sterling Option I
Summit Claims Center
Superior Vision Plan
Superior Vision Services, Inc
TennCare Select
Tennessee Health Care
Tennessee Health Care Attn: Repricing Dept.
Tennessee Valley Operating Engineers Health Fund
Tennessee Valley Painters Health Fund
THA Solutions Group
Thrivent Financial
TICUA Benefit Consortium c/o Meritain Health
Time Insurance Company
TN Carpenters Regional Council Hlth & Welfare Fund
TN PPO PPA Direct
Transamerica Life Ins Co
Tricare Military Healthcare w/ Humana
TriWest WPS-VAPC3 (do not use 2020)
Trustmark Life Insurance Company
TVA Johnsonville Fossil Plant
U.A. Local Union No. 614
UMR
Unicare
UniCare - The Chandler Group
Unified Group Services
Unimin Corp
Union Pacific Railroad Employees Health Systems
Unison Advantage
United American Ins Co
United Commercial Travelers
United Health Care-Dual Complete
United Health Care-Students
United Health Care Oxford
United Health Care/TX
United Healthcare - Railroad
United Healthcare Community Plan
United Healthcare River Valley
United Healthcare/ UT
United Healthcare/Atlanta
United Insurance Company of America
United Life Insurance Company
United Service Association For Health Care
United Teacher Associates Ins Com
United Way
United World Life Ins Co
UnitedHealthcare-Choice Plus
US Dept of Labor-OWCP
US Health & Life
USA +Claims Service
USA H&W Network
USA MCO
VA Health Net Patient Centered Community Care
Valley West Welding Company
VES Services
Vision Benefits of America
Vision Care Plan
Vision Service Plan
Vision Source
Vocational Rehab
VSP Discount Plan
Wagner Construction
Watkins Associated Industries, Inc.
Wausau Benefits
Waverly Wood
WEBTPA
WellCare
Western United Life
William C Beeler and Company
Willis Corroon Administrative Corp
Windsor Health Plans Claims(WellCare---we do not take medical-vision is Superior)
Woodmen of the World
Workers Compensation
WPS VAPC3 (do not use 2020)
Zurich North America
Zyrec Insurance
Insurance Plan:
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:
Third Med
Insurance Information
Insurance Name:
None
AARP
AARP Discount Program
Accident Fund
Ace American Ins Co
Acordia Senior of the South
ACS/GlobalCare, Inc
Administrative Concepts
Admiral Life Insurance Company of America
Advantra Freedom
Aetna
Aetna Health
Aetna Life Advantage Medicare Program
Aetna One Vision Discount
AIG Domestic Claim
Alicare
Aliera Care
All Savers
Allied Benefit Systems, Inc
Alpha Review Corporation
AlwaysCare Vision Claims
Ambetter (We are not in network)
AmComp Claims Department
American Business Coalition
American Continental Ins Co
American Health Group
American Heritage LIfe Ins Co
American Medical Security
American Pioneer Life
American Republic Ins Co
American Republic Insurance Co.
Americhoice
Americo Financial Life
Amerigroup
AmeriHealth Administrators
Ameritas
Amerivantage
Anthem Blue Cross Blue Shield
APWU Health Plan
Arnold Fabricating & Machine
Assurant Health
Assurant Health Attn: Claims
AssureCare of Illinois
Attorney pmt for medical records
Auto-Owners Insurance
Avesis
AWA PMT
Bankers Fidelity
Bankers Life & Casualty
Belisle Machine
Benefit Consultants, Inc
Benefit Planners
Benefits Assistance Corp.
Benefits Department
Benesight
Benton County Electric System
Benton County Ministerial Alliance
Benton County Sheriff's Department
Block Vision/Superior Vision
Blue Advantage
Blue Care
Blue Care Plus
Blue Cross Blue Shield of Tennessee
Blue Perks Discount
Bluegrass Family Health Network
Boilermakers National Fund-----BNF
Boon Chapman Benefit Administrators
Broadspire Services
Brookshire Hathaway
CAHABA GBA PART B Medicare
Camden Machine Works
Capitol Administrators of the Southeast
Carey & Counseling Attn: A/P
CBA
Central Benefits
Central State Health & Life Co.
Central States Southeast and Southwest Areas
Central United Life
Century Healthcare, LLC
CHAMPVA
Chartis
Cherokee Insurance Company
Cigna Government Services
Cigna Health Care
Cigna Health Spring/Medicare
Cigna Healthcare
Cigna International
Cigna Medical (Boilermakers)
Cigna PPO
Cigna Total Choice Medicare/American Retirement
Cigna Vision, Claims Dept
CignaHealthCare
City of Camden
Claims Office
Claims Processing Contractor
Closing The Gap
Coast to Coast Discount Plan
Cole Vision 10% Discount Plan
Colonial Penn
Combined
Community Eye Care
Community Health Alliance
Community Service Network of West TN
Companion Life
Compbenefits
Concentra Tampa Technology Center
Connecticut General Life Ins. Co
Conseco
Consumers Insurance
Continental General Insurance Company
Continental Life Ins. Co.
Cornerstone - Attn: Candace
Country Club & Grill
Country Life Insurance Company
Covenant Administrators, Inc.
Coventry Health Care
Cover Kids-BCBS
Cover Kids-EyeQuest
Cover Kids-March
Crossamerica Health Plans
CSI
Dana
Davis Vision
Davis Vision Discount Plan
Days & Zimmerman - NPS Workers Comp
Department of Veterans Affairs
Deseret Mutual
Discount Plan
Douglas County Separate Juvenile Court
Dunn and Associates
EBC Mid America
EBMS
ECPA Claims Administration
Equipoint
Equitable Life & Casualty
Essilor
Everest
Eye Med Vision Care
Eyeconic-VSP
Eyemed Discount Plan
EyeQuest
Family Life Ins Co
Farm Bureau Agency
Farm Bureau Health Plans
Federated Insurance
FEP Vision Discount
First Comp
First Health
First Script DME Plus Claims Dept
Fox Everett
Frank Lill & Son Inc.
Gallagher Bassett Service, Inc.
Gallagher Bassett Services, Inc.
GEHA
Gerber Life Insurance
GHI
Golden Rule Insurance
GPM Life
Great-West Healthcare
Great American Life Ins Co
Guarantee Trust Life
Guardian
Guardian Insurance-Vision Processing Unit
Gulf Guaranty Claims
GWH Cigna
Hamilton Ryker Attn: Ladona
Hartford Life
Health Cost Companies
Health Partners
Health Plan
HealthComp - NovaNet, Inc
HealthScope Benefits, Inc
Healthsmart
HealthSpring Medicare
Heartland National
HMA Insurance
HMA, LLC
Hughes & Coleman Injury Lawyers
Humana
Humana Vision Discount
Humana Gold Choice
Humphreys County Sheriff
IAC
Infant See
Insurance Benefits System Administrators c/o Zelis
John Alden Life Insurance Company
Jones Plastic Workers Comp
Kaiser Foundation Health Claims Dept.
Key Benefit Administrators, Inc.
KHS-Humana
Lensferry
LHI - Attn Accounts Payable
Liberty Mutual
Life Care Centers of America
Lincoln Heritage Life Ins
Lions Club
LMI
Loomis
Loyal American
Lumbermans Underwriting Alliance
Lumico
Magpro
Mail Handlers Benefit Plan
ManageMED
Manhattan Life Ins Co
March Vision
Marsh Advantage America
MedCo Health Solutions, Inc
Medi-Share
Medicaid
Medical Mutual
Mediplus
Meritain Health Minneapolis
Met Life
Mid Central Operating Engineers
Mid South Carpenters Regional Council
Midway Materials
Midwest National Life Insurance
Midwest Operating Engineers Welfare Fund
Military Benefit Association
MMS
Monumental Life Insurance Co
Motorola
Mutual of Omaha
Mutual of Omaha Manufacturing Companies
N E I H B P
NALC Health Benefit Plan
Natchez Trace Youth Academy
National Asbestos Workers Fund
National Care Network
National States Insurance Company
Nationwide Life Insurance
Nationwide Specialty Health Claims
NECA/IBEW Family Medical Care Plan
New Era Life Insurance Co
New Insurance
NGS American, Inc
Nippon Life Ins Co of America
Norman Marine
North America Industries, Inc.
North American Administration L.P.
Northwest Administrative Office
Northwest Tennessee Headstart
Nova Healthcare Administrators, Inc.
Nova Net
NVA
ODS-OHP Medical Claims
Operating Engineers Health
Operating Engineers Locals Welfare Trust Fund
Pacific Life Annuity
PAI
Palmer Tool, LLC
Palmetto GBA Medicare - Palmetto GBA Medicare
Pan American Benefits Solutions
Pearce Administration
Pennsylvania Life Ins Co
PersonalCare
Philadelphia American Life Ins Co
Physicians Mutual
Plumbers & Pipefitters #572
PML / USA H&W Network
POMCO Group
PPOM
Premier Eye Care
Principal Financial Group
Principal Life Ins
Prudential/AARP Claim Unit
Pyramid Claims
Pyramid Life
QMB
QualChoice of Arkansas, Inc
Railroad Medicare
Renaissance Life
Reserve National Insurance Company
Robins Insurance Agency
Roll Tooling Specialist
Royal Neighbors of America
RSL Specialty Products Administration
Rural Carrier Benefit Plan
Safety Specs Pmt
Secure Horizons
Secure Plus
Sedgwick
Select Benefit Administrators of America
Sentry Insurance Claims Dept.
Shenandoah Life Insurance
Signature Health Alliance
Simple
SISCO - Self Insured Services Co.
Southeast Laborers Health Fund
Southern Benefit Administrators, Inc
Southern Guarantee
Southwest Human Resource Agency
Spectera
Standard Life & Accident
Standard Security Life Ins Co
Star HRG-Galaxy Health Network
Starmark
State Farm Insurance Companies
State of Tennessee
Sterling Investors
Sterling Option I
Summit Claims Center
Superior Vision Plan
Superior Vision Services, Inc
TennCare Select
Tennessee Health Care
Tennessee Health Care Attn: Repricing Dept.
Tennessee Valley Operating Engineers Health Fund
Tennessee Valley Painters Health Fund
THA Solutions Group
Thrivent Financial
TICUA Benefit Consortium c/o Meritain Health
Time Insurance Company
TN Carpenters Regional Council Hlth & Welfare Fund
TN PPO PPA Direct
Transamerica Life Ins Co
Tricare Military Healthcare w/ Humana
TriWest WPS-VAPC3 (do not use 2020)
Trustmark Life Insurance Company
TVA Johnsonville Fossil Plant
U.A. Local Union No. 614
UMR
Unicare
UniCare - The Chandler Group
Unified Group Services
Unimin Corp
Union Pacific Railroad Employees Health Systems
Unison Advantage
United American Ins Co
United Commercial Travelers
United Health Care-Dual Complete
United Health Care-Students
United Health Care Oxford
United Health Care/TX
United Healthcare - Railroad
United Healthcare Community Plan
United Healthcare River Valley
United Healthcare/ UT
United Healthcare/Atlanta
United Insurance Company of America
United Life Insurance Company
United Service Association For Health Care
United Teacher Associates Ins Com
United Way
United World Life Ins Co
UnitedHealthcare-Choice Plus
US Dept of Labor-OWCP
US Health & Life
USA +Claims Service
USA H&W Network
USA MCO
VA Health Net Patient Centered Community Care
Valley West Welding Company
VES Services
Vision Benefits of America
Vision Care Plan
Vision Service Plan
Vision Source
Vocational Rehab
VSP Discount Plan
Wagner Construction
Watkins Associated Industries, Inc.
Wausau Benefits
Waverly Wood
WEBTPA
WellCare
Western United Life
William C Beeler and Company
Willis Corroon Administrative Corp
Windsor Health Plans Claims(WellCare---we do not take medical-vision is Superior)
Woodmen of the World
Workers Compensation
WPS VAPC3 (do not use 2020)
Zurich North America
Zyrec Insurance
Insurance Plan:
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:
Vision Plan
Insurance Information
Insurance Name:
None
AARP
AARP Discount Program
Accident Fund
Ace American Ins Co
Acordia Senior of the South
ACS/GlobalCare, Inc
Administrative Concepts
Admiral Life Insurance Company of America
Advantra Freedom
Aetna
Aetna Health
Aetna Life Advantage Medicare Program
Aetna One Vision Discount
AIG Domestic Claim
Alicare
Aliera Care
All Savers
Allied Benefit Systems, Inc
Alpha Review Corporation
AlwaysCare Vision Claims
Ambetter (We are not in network)
AmComp Claims Department
American Business Coalition
American Continental Ins Co
American Health Group
American Heritage LIfe Ins Co
American Medical Security
American Pioneer Life
American Republic Ins Co
American Republic Insurance Co.
Americhoice
Americo Financial Life
Amerigroup
AmeriHealth Administrators
Ameritas
Amerivantage
Anthem Blue Cross Blue Shield
APWU Health Plan
Arnold Fabricating & Machine
Assurant Health
Assurant Health Attn: Claims
AssureCare of Illinois
Attorney pmt for medical records
Auto-Owners Insurance
Avesis
AWA PMT
Bankers Fidelity
Bankers Life & Casualty
Belisle Machine
Benefit Consultants, Inc
Benefit Planners
Benefits Assistance Corp.
Benefits Department
Benesight
Benton County Electric System
Benton County Ministerial Alliance
Benton County Sheriff's Department
Block Vision/Superior Vision
Blue Advantage
Blue Care
Blue Care Plus
Blue Cross Blue Shield of Tennessee
Blue Perks Discount
Bluegrass Family Health Network
Boilermakers National Fund-----BNF
Boon Chapman Benefit Administrators
Broadspire Services
Brookshire Hathaway
CAHABA GBA PART B Medicare
Camden Machine Works
Capitol Administrators of the Southeast
Carey & Counseling Attn: A/P
CBA
Central Benefits
Central State Health & Life Co.
Central States Southeast and Southwest Areas
Central United Life
Century Healthcare, LLC
CHAMPVA
Chartis
Cherokee Insurance Company
Cigna Government Services
Cigna Health Care
Cigna Health Spring/Medicare
Cigna Healthcare
Cigna International
Cigna Medical (Boilermakers)
Cigna PPO
Cigna Total Choice Medicare/American Retirement
Cigna Vision, Claims Dept
CignaHealthCare
City of Camden
Claims Office
Claims Processing Contractor
Closing The Gap
Coast to Coast Discount Plan
Cole Vision 10% Discount Plan
Colonial Penn
Combined
Community Eye Care
Community Health Alliance
Community Service Network of West TN
Companion Life
Compbenefits
Concentra Tampa Technology Center
Connecticut General Life Ins. Co
Conseco
Consumers Insurance
Continental General Insurance Company
Continental Life Ins. Co.
Cornerstone - Attn: Candace
Country Club & Grill
Country Life Insurance Company
Covenant Administrators, Inc.
Coventry Health Care
Cover Kids-BCBS
Cover Kids-EyeQuest
Cover Kids-March
Crossamerica Health Plans
CSI
Dana
Davis Vision
Davis Vision Discount Plan
Days & Zimmerman - NPS Workers Comp
Department of Veterans Affairs
Deseret Mutual
Discount Plan
Douglas County Separate Juvenile Court
Dunn and Associates
EBC Mid America
EBMS
ECPA Claims Administration
Equipoint
Equitable Life & Casualty
Essilor
Everest
Eye Med Vision Care
Eyeconic-VSP
Eyemed Discount Plan
EyeQuest
Family Life Ins Co
Farm Bureau Agency
Farm Bureau Health Plans
Federated Insurance
FEP Vision Discount
First Comp
First Health
First Script DME Plus Claims Dept
Fox Everett
Frank Lill & Son Inc.
Gallagher Bassett Service, Inc.
Gallagher Bassett Services, Inc.
GEHA
Gerber Life Insurance
GHI
Golden Rule Insurance
GPM Life
Great-West Healthcare
Great American Life Ins Co
Guarantee Trust Life
Guardian
Guardian Insurance-Vision Processing Unit
Gulf Guaranty Claims
GWH Cigna
Hamilton Ryker Attn: Ladona
Hartford Life
Health Cost Companies
Health Partners
Health Plan
HealthComp - NovaNet, Inc
HealthScope Benefits, Inc
Healthsmart
HealthSpring Medicare
Heartland National
HMA Insurance
HMA, LLC
Hughes & Coleman Injury Lawyers
Humana
Humana Vision Discount
Humana Gold Choice
Humphreys County Sheriff
IAC
Infant See
Insurance Benefits System Administrators c/o Zelis
John Alden Life Insurance Company
Jones Plastic Workers Comp
Kaiser Foundation Health Claims Dept.
Key Benefit Administrators, Inc.
KHS-Humana
Lensferry
LHI - Attn Accounts Payable
Liberty Mutual
Life Care Centers of America
Lincoln Heritage Life Ins
Lions Club
LMI
Loomis
Loyal American
Lumbermans Underwriting Alliance
Lumico
Magpro
Mail Handlers Benefit Plan
ManageMED
Manhattan Life Ins Co
March Vision
Marsh Advantage America
MedCo Health Solutions, Inc
Medi-Share
Medicaid
Medical Mutual
Mediplus
Meritain Health Minneapolis
Met Life
Mid Central Operating Engineers
Mid South Carpenters Regional Council
Midway Materials
Midwest National Life Insurance
Midwest Operating Engineers Welfare Fund
Military Benefit Association
MMS
Monumental Life Insurance Co
Motorola
Mutual of Omaha
Mutual of Omaha Manufacturing Companies
N E I H B P
NALC Health Benefit Plan
Natchez Trace Youth Academy
National Asbestos Workers Fund
National Care Network
National States Insurance Company
Nationwide Life Insurance
Nationwide Specialty Health Claims
NECA/IBEW Family Medical Care Plan
New Era Life Insurance Co
New Insurance
NGS American, Inc
Nippon Life Ins Co of America
Norman Marine
North America Industries, Inc.
North American Administration L.P.
Northwest Administrative Office
Northwest Tennessee Headstart
Nova Healthcare Administrators, Inc.
Nova Net
NVA
ODS-OHP Medical Claims
Operating Engineers Health
Operating Engineers Locals Welfare Trust Fund
Pacific Life Annuity
PAI
Palmer Tool, LLC
Palmetto GBA Medicare - Palmetto GBA Medicare
Pan American Benefits Solutions
Pearce Administration
Pennsylvania Life Ins Co
PersonalCare
Philadelphia American Life Ins Co
Physicians Mutual
Plumbers & Pipefitters #572
PML / USA H&W Network
POMCO Group
PPOM
Premier Eye Care
Principal Financial Group
Principal Life Ins
Prudential/AARP Claim Unit
Pyramid Claims
Pyramid Life
QMB
QualChoice of Arkansas, Inc
Railroad Medicare
Renaissance Life
Reserve National Insurance Company
Robins Insurance Agency
Roll Tooling Specialist
Royal Neighbors of America
RSL Specialty Products Administration
Rural Carrier Benefit Plan
Safety Specs Pmt
Secure Horizons
Secure Plus
Sedgwick
Select Benefit Administrators of America
Sentry Insurance Claims Dept.
Shenandoah Life Insurance
Signature Health Alliance
Simple
SISCO - Self Insured Services Co.
Southeast Laborers Health Fund
Southern Benefit Administrators, Inc
Southern Guarantee
Southwest Human Resource Agency
Spectera
Standard Life & Accident
Standard Security Life Ins Co
Star HRG-Galaxy Health Network
Starmark
State Farm Insurance Companies
State of Tennessee
Sterling Investors
Sterling Option I
Summit Claims Center
Superior Vision Plan
Superior Vision Services, Inc
TennCare Select
Tennessee Health Care
Tennessee Health Care Attn: Repricing Dept.
Tennessee Valley Operating Engineers Health Fund
Tennessee Valley Painters Health Fund
THA Solutions Group
Thrivent Financial
TICUA Benefit Consortium c/o Meritain Health
Time Insurance Company
TN Carpenters Regional Council Hlth & Welfare Fund
TN PPO PPA Direct
Transamerica Life Ins Co
Tricare Military Healthcare w/ Humana
TriWest WPS-VAPC3 (do not use 2020)
Trustmark Life Insurance Company
TVA Johnsonville Fossil Plant
U.A. Local Union No. 614
UMR
Unicare
UniCare - The Chandler Group
Unified Group Services
Unimin Corp
Union Pacific Railroad Employees Health Systems
Unison Advantage
United American Ins Co
United Commercial Travelers
United Health Care-Dual Complete
United Health Care-Students
United Health Care Oxford
United Health Care/TX
United Healthcare - Railroad
United Healthcare Community Plan
United Healthcare River Valley
United Healthcare/ UT
United Healthcare/Atlanta
United Insurance Company of America
United Life Insurance Company
United Service Association For Health Care
United Teacher Associates Ins Com
United Way
United World Life Ins Co
UnitedHealthcare-Choice Plus
US Dept of Labor-OWCP
US Health & Life
USA +Claims Service
USA H&W Network
USA MCO
VA Health Net Patient Centered Community Care
Valley West Welding Company
VES Services
Vision Benefits of America
Vision Care Plan
Vision Service Plan
Vision Source
Vocational Rehab
VSP Discount Plan
Wagner Construction
Watkins Associated Industries, Inc.
Wausau Benefits
Waverly Wood
WEBTPA
WellCare
Western United Life
William C Beeler and Company
Willis Corroon Administrative Corp
Windsor Health Plans Claims(WellCare---we do not take medical-vision is Superior)
Woodmen of the World
Workers Compensation
WPS VAPC3 (do not use 2020)
Zurich North America
Zyrec Insurance
Insurance Plan:
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:
2nd Vision
Insurance Information
Insurance Name:
None
AARP
AARP Discount Program
Accident Fund
Ace American Ins Co
Acordia Senior of the South
ACS/GlobalCare, Inc
Administrative Concepts
Admiral Life Insurance Company of America
Advantra Freedom
Aetna
Aetna Health
Aetna Life Advantage Medicare Program
Aetna One Vision Discount
AIG Domestic Claim
Alicare
Aliera Care
All Savers
Allied Benefit Systems, Inc
Alpha Review Corporation
AlwaysCare Vision Claims
Ambetter (We are not in network)
AmComp Claims Department
American Business Coalition
American Continental Ins Co
American Health Group
American Heritage LIfe Ins Co
American Medical Security
American Pioneer Life
American Republic Ins Co
American Republic Insurance Co.
Americhoice
Americo Financial Life
Amerigroup
AmeriHealth Administrators
Ameritas
Amerivantage
Anthem Blue Cross Blue Shield
APWU Health Plan
Arnold Fabricating & Machine
Assurant Health
Assurant Health Attn: Claims
AssureCare of Illinois
Attorney pmt for medical records
Auto-Owners Insurance
Avesis
AWA PMT
Bankers Fidelity
Bankers Life & Casualty
Belisle Machine
Benefit Consultants, Inc
Benefit Planners
Benefits Assistance Corp.
Benefits Department
Benesight
Benton County Electric System
Benton County Ministerial Alliance
Benton County Sheriff's Department
Block Vision/Superior Vision
Blue Advantage
Blue Care
Blue Care Plus
Blue Cross Blue Shield of Tennessee
Blue Perks Discount
Bluegrass Family Health Network
Boilermakers National Fund-----BNF
Boon Chapman Benefit Administrators
Broadspire Services
Brookshire Hathaway
CAHABA GBA PART B Medicare
Camden Machine Works
Capitol Administrators of the Southeast
Carey & Counseling Attn: A/P
CBA
Central Benefits
Central State Health & Life Co.
Central States Southeast and Southwest Areas
Central United Life
Century Healthcare, LLC
CHAMPVA
Chartis
Cherokee Insurance Company
Cigna Government Services
Cigna Health Care
Cigna Health Spring/Medicare
Cigna Healthcare
Cigna International
Cigna Medical (Boilermakers)
Cigna PPO
Cigna Total Choice Medicare/American Retirement
Cigna Vision, Claims Dept
CignaHealthCare
City of Camden
Claims Office
Claims Processing Contractor
Closing The Gap
Coast to Coast Discount Plan
Cole Vision 10% Discount Plan
Colonial Penn
Combined
Community Eye Care
Community Health Alliance
Community Service Network of West TN
Companion Life
Compbenefits
Concentra Tampa Technology Center
Connecticut General Life Ins. Co
Conseco
Consumers Insurance
Continental General Insurance Company
Continental Life Ins. Co.
Cornerstone - Attn: Candace
Country Club & Grill
Country Life Insurance Company
Covenant Administrators, Inc.
Coventry Health Care
Cover Kids-BCBS
Cover Kids-EyeQuest
Cover Kids-March
Crossamerica Health Plans
CSI
Dana
Davis Vision
Davis Vision Discount Plan
Days & Zimmerman - NPS Workers Comp
Department of Veterans Affairs
Deseret Mutual
Discount Plan
Douglas County Separate Juvenile Court
Dunn and Associates
EBC Mid America
EBMS
ECPA Claims Administration
Equipoint
Equitable Life & Casualty
Essilor
Everest
Eye Med Vision Care
Eyeconic-VSP
Eyemed Discount Plan
EyeQuest
Family Life Ins Co
Farm Bureau Agency
Farm Bureau Health Plans
Federated Insurance
FEP Vision Discount
First Comp
First Health
First Script DME Plus Claims Dept
Fox Everett
Frank Lill & Son Inc.
Gallagher Bassett Service, Inc.
Gallagher Bassett Services, Inc.
GEHA
Gerber Life Insurance
GHI
Golden Rule Insurance
GPM Life
Great-West Healthcare
Great American Life Ins Co
Guarantee Trust Life
Guardian
Guardian Insurance-Vision Processing Unit
Gulf Guaranty Claims
GWH Cigna
Hamilton Ryker Attn: Ladona
Hartford Life
Health Cost Companies
Health Partners
Health Plan
HealthComp - NovaNet, Inc
HealthScope Benefits, Inc
Healthsmart
HealthSpring Medicare
Heartland National
HMA Insurance
HMA, LLC
Hughes & Coleman Injury Lawyers
Humana
Humana Vision Discount
Humana Gold Choice
Humphreys County Sheriff
IAC
Infant See
Insurance Benefits System Administrators c/o Zelis
John Alden Life Insurance Company
Jones Plastic Workers Comp
Kaiser Foundation Health Claims Dept.
Key Benefit Administrators, Inc.
KHS-Humana
Lensferry
LHI - Attn Accounts Payable
Liberty Mutual
Life Care Centers of America
Lincoln Heritage Life Ins
Lions Club
LMI
Loomis
Loyal American
Lumbermans Underwriting Alliance
Lumico
Magpro
Mail Handlers Benefit Plan
ManageMED
Manhattan Life Ins Co
March Vision
Marsh Advantage America
MedCo Health Solutions, Inc
Medi-Share
Medicaid
Medical Mutual
Mediplus
Meritain Health Minneapolis
Met Life
Mid Central Operating Engineers
Mid South Carpenters Regional Council
Midway Materials
Midwest National Life Insurance
Midwest Operating Engineers Welfare Fund
Military Benefit Association
MMS
Monumental Life Insurance Co
Motorola
Mutual of Omaha
Mutual of Omaha Manufacturing Companies
N E I H B P
NALC Health Benefit Plan
Natchez Trace Youth Academy
National Asbestos Workers Fund
National Care Network
National States Insurance Company
Nationwide Life Insurance
Nationwide Specialty Health Claims
NECA/IBEW Family Medical Care Plan
New Era Life Insurance Co
New Insurance
NGS American, Inc
Nippon Life Ins Co of America
Norman Marine
North America Industries, Inc.
North American Administration L.P.
Northwest Administrative Office
Northwest Tennessee Headstart
Nova Healthcare Administrators, Inc.
Nova Net
NVA
ODS-OHP Medical Claims
Operating Engineers Health
Operating Engineers Locals Welfare Trust Fund
Pacific Life Annuity
PAI
Palmer Tool, LLC
Palmetto GBA Medicare - Palmetto GBA Medicare
Pan American Benefits Solutions
Pearce Administration
Pennsylvania Life Ins Co
PersonalCare
Philadelphia American Life Ins Co
Physicians Mutual
Plumbers & Pipefitters #572
PML / USA H&W Network
POMCO Group
PPOM
Premier Eye Care
Principal Financial Group
Principal Life Ins
Prudential/AARP Claim Unit
Pyramid Claims
Pyramid Life
QMB
QualChoice of Arkansas, Inc
Railroad Medicare
Renaissance Life
Reserve National Insurance Company
Robins Insurance Agency
Roll Tooling Specialist
Royal Neighbors of America
RSL Specialty Products Administration
Rural Carrier Benefit Plan
Safety Specs Pmt
Secure Horizons
Secure Plus
Sedgwick
Select Benefit Administrators of America
Sentry Insurance Claims Dept.
Shenandoah Life Insurance
Signature Health Alliance
Simple
SISCO - Self Insured Services Co.
Southeast Laborers Health Fund
Southern Benefit Administrators, Inc
Southern Guarantee
Southwest Human Resource Agency
Spectera
Standard Life & Accident
Standard Security Life Ins Co
Star HRG-Galaxy Health Network
Starmark
State Farm Insurance Companies
State of Tennessee
Sterling Investors
Sterling Option I
Summit Claims Center
Superior Vision Plan
Superior Vision Services, Inc
TennCare Select
Tennessee Health Care
Tennessee Health Care Attn: Repricing Dept.
Tennessee Valley Operating Engineers Health Fund
Tennessee Valley Painters Health Fund
THA Solutions Group
Thrivent Financial
TICUA Benefit Consortium c/o Meritain Health
Time Insurance Company
TN Carpenters Regional Council Hlth & Welfare Fund
TN PPO PPA Direct
Transamerica Life Ins Co
Tricare Military Healthcare w/ Humana
TriWest WPS-VAPC3 (do not use 2020)
Trustmark Life Insurance Company
TVA Johnsonville Fossil Plant
U.A. Local Union No. 614
UMR
Unicare
UniCare - The Chandler Group
Unified Group Services
Unimin Corp
Union Pacific Railroad Employees Health Systems
Unison Advantage
United American Ins Co
United Commercial Travelers
United Health Care-Dual Complete
United Health Care-Students
United Health Care Oxford
United Health Care/TX
United Healthcare - Railroad
United Healthcare Community Plan
United Healthcare River Valley
United Healthcare/ UT
United Healthcare/Atlanta
United Insurance Company of America
United Life Insurance Company
United Service Association For Health Care
United Teacher Associates Ins Com
United Way
United World Life Ins Co
UnitedHealthcare-Choice Plus
US Dept of Labor-OWCP
US Health & Life
USA +Claims Service
USA H&W Network
USA MCO
VA Health Net Patient Centered Community Care
Valley West Welding Company
VES Services
Vision Benefits of America
Vision Care Plan
Vision Service Plan
Vision Source
Vocational Rehab
VSP Discount Plan
Wagner Construction
Watkins Associated Industries, Inc.
Wausau Benefits
Waverly Wood
WEBTPA
WellCare
Western United Life
William C Beeler and Company
Willis Corroon Administrative Corp
Windsor Health Plans Claims(WellCare---we do not take medical-vision is Superior)
Woodmen of the World
Workers Compensation
WPS VAPC3 (do not use 2020)
Zurich North America
Zyrec Insurance
Insurance Plan:
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
Briefly describe the main reason for having an examination today:
Other
Associated: Do you have any other symptoms related to this?
none
dizzy
headache
loss of vision
blurred vision
Other
Other eye issues or problems
Full-time
Part-time
If part-time, how often/when?
Occasionally
Driving
Reading / Computer
After contact lens removal
1-2 times per week
Half time
Sports
Weekends
Social activities
Other
Full-time
Part-time
If part-time, how often/when?
Occasionally
Driving
1-2 times per week
Half time
Sports
Weekends
Social activities
Other
Soft
Rigid Gas Permeable
Yes
No
Current Brand:
Acuvue 1-day
Acuvue 1-day Moist
Acuvue 1-day Trueye
Acuvue 2
Acuvue Oasys
Acuvue Oasys for Astigmatism
Acuvue Oasys for Presbyopia
Acuvue Advance
Acuvue Advance for Astigmatism
Air Optix
Air Optix Night & Day
Air Optix Astigmatism
Air Optix Multifocal
Avaira
Biomedic Toric
Biomedic XC
Biofinity
Biofinity Toric
Biofinity Multifocal
Clearsight 1 day
Clearsight 1 day Toric
Focus Dailies Standard
Focus Dailies AC plus
Focus Dailies Toric
Frequency 55
Frequency 55 Toric
Frequency 55 Aspheric
Freshlook colorblends
Proclear
Proclear 1 day
Proclear EP
Proclear Multifocal
Purevision
Purevision 2
Purevision 2 Toric
Purevision Multifocal
Soflens 38
Soflens Toric
Soflens Daily Disposable
Soflens Multifocal
Vertex Toric
Boston EO
Boston ES
Boston XO
Fluoroperm 60
Menicon Z Thin
RGP - unknown material
Other
What solution do you use?
None
Optifree Replenish
Optifree Pure Moist
Optifree Express
Renu
Biotrue
Clear Care
Kirkland Signature
Revitalens
Generic store brand
Boston Advance
Boston original
Optimum
B & L Gas Perm
Unique Ph
Other
What is your replacement schedule?
Daily
Weekly
Every 2 weeks
Monthly
If they feel bad
Quarterly
Yearly
Other
How old is your current pair?
new
1-2 weeks
2-4 weeks
very old
Other
Please list all eyedrops you use (OTC and Rx):
none
Blink
Genteal
Optive
Refresh Plus
Similisan
Systane
Generic artificial tears
Murine
Visine
Lumigan
Travatan
Xalatan
Timoptic
Other
How often used?:
daily
occasionally
rarely
Other
Blindness
Eye Turn
Lazy Eye
Keratoconus
Macular Degeneration
Retinal Detachment
Glaucoma
Cataracts
Headaches
Blurred Vision
Double Vision
Eyes "hurt or tired"
Halos around lights
Bothered by light/sun
Frequent Styes
Eyes frequently red
Eyes itch
Eyes Burn
Eyes tear
Eyes feel dry
Eyes feel sandy/gritty
Flashing Lights
Floaters
Other eye disease or condition
none
Other
Describe any eye injuries:
none
Other
List any eye surgeries:
none
Other
How many hours a day do you use a computer?
<2 hours
2 - 4 hours
5 - 8 hours
9 - 12 hours
12+ hours
Other
Describe any visual symptoms from computer use:
none
Eye strain
Blurred vision
Headache
Dry eyes
Watery
Itch
Burn
Double vision
Other
Are you pregnant or nursing?
Yes
No If yes, what is the due/birth date?
Allergies/Hay fever
Multiple Sclerosis
Diabetes
Thyroid problems
Arthritis
Migraines
Asthma
Emphysema
High blood pressure
Stroke
Anemia
Cancer
Notes:
BMI
Weight
Physician's Name:
Deborah Woods
Fast Pace
Jason Hollingsworth
Ken Berry
Lynn Dicus
McKenzie Medical Center
Steve Canady
Terry Harrison
Verneda Herring
Other
Last Visit Date:
>
How often do you consume alcohol:
Never
Occasionally
Daily
Other
Hepatitis
HIV
STDs
Who referred you to our office?
If not referred, how did you hear about The Eyecare Center?
Family member
Insurance list
Coworker
Friend
Primary Care Doctor
Internet
Drove by
Other
Does your family have a history of these diseases?
Poor Vision
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
Blindness
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
Eye turn
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
Lazy Eye
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
Glaucoma
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
Cataracts
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
Cancer
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
Diabetes
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
High Blood Pressure
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
Stroke
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
Thyroid
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
Other Inherited Disease
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
Macular Degeneration
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
Retinal Detachment/Disease
Mother
Father
Sister
Brother
Aunt
Uncle
Parents
Grandparent(s)
Other
Date
Occupation:
Employer:
Counseled pt on not smoking
Family history is unknown/adopted
How often do you smoke/use tobacco products?
Never
Occasionally
Daily
Other
Signatures/Submit Data
Click here for Privacy Policy
I have read and agree to the above policy:
Patients E-Signature:
Date:
Click here for Patient Responsibility
Optomap Retinal Exam:
Our doctors highly recommend that you have an Optomap Retinal Exam. The Optomap is a comprehensive method of evaluating, monitoring, and helping treat various eye conditions.
There will be a $30.00 charge for this service that insurance will not cover.
Yes, Optomap approved
Not sure, need to discuss.
I have read and agree to the above policy:
Patients E-Signature:
Date: