New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	AL AK AZ AR TX 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

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. Glusman, Murray	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address

City	State	ZipCode
	AL AK AZ AR TX 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

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP/MEDICARE COMPLETE AARP/UNITED HEALTHCARE CLAIM DIVISION ADVANTRA FREEDOM AETNA AETNA HEALTH AETNA LIFE INSURANCE COMPANY AHS STATE NETWORK AIG CLAIM SERVICES ALFA INSURANCE ALLIANT HEALTH PLAN, INC. ALLIED BENEFITS ALLSTATE CLAIMS ALTERNATIVE INSURANCE RESOURCES INC ALWAYS CARE BENEFITS INC AMA INSURANCE AGENCY AMERICAN PUBLIC LIFE AMERISAFE APPALACHIAN PIPELINE APWU HEALTH PLAN ASI Assurant Health ASSURANT HEALTH AVMA GROUP HEALTH AND LIFE INSURANCE TRUST BALL STATE UNIVERSITY BANKERS LIFE BANKERS LIFE AND CASUALTY BEECH STREET BENEFIT MANGEMENT SERVICE BERKLEY RISK ADMIN BLOCK VISION BLUE BELL HEALTH BENEFITS BLUE CROSS BLUE SHIELD BMS BOILERMAKERS BOILERMAKERS VISION CARPENTERS H&W/CMR CBS INC CENTRAL STATES SOUTHEAST CHAMP VA CHESTERFIELD RESOURCES CHOUEST GROUP HEALTH PLAN PPOPLUS, LLC CIGNA CIGNA GOVERNMENT SERVICES CIGNA/SAMBA HEALTH COMPBENEFITS-HUMANA CONSOLIDATED HEALTH PLANS CONTINENTAL LIFE CORPORATE BENEFITS SERVICE CORROSION MONOTORING DAUPHIN ISLAND VOL FIRE DEPT DEANS SCRAP METAL DEFINITY HEALTH Encompass Insurance EPS FAMILY LIFE INSURANCE COMPANY FIRST HEALTH NETWORK FISERV HEALTH FOX-EVERETT INC. GALLAGHER BASSETT SERVICES INC GE LIFE AND ANNUITY ASSURANCE CO. GEHA PPO USA GHI GILSBAR INC GLOBAL MEDICAL MANAGEMENT INC GOLDEN RULE INSURANCE COMPANY GREAT WEST HEALTHCARE GROUP ADMINISTRATORS LTD. GROUP AND PENSION ADMINSITRATORS INC GROUP RESOURCES INC GUARDIAN GROUP CLAIMS GULF HEALTH PLAN PPO-AIR INC. HEALTH NET MEDICARE ADVANTAGE HEALTHEOS HEALTHSCOPE INS HEALTHSMART HEALTHSPRING CLAIMS HIGHMARK BENEFITS HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY HTH WORLDWIDE INSURANCE SERVICES HTH/ AETNA GLOBAL BENEFITS HUMANA JESUIT HEALTH TRUST HMSR-CHRISTIAN BROTHERS SERVIC KEY BENEFIT ADMINSTRATORS LIONS CLUB LOYAL AMERICAN LIFE INS CO MAIL HANDLERS BENEFIT PLAN MARQUETTA NATIONAL LIFE INS./TODAY'S OPTION MEDICAL MUTUAL MEDICARE PART B MEDICARE PART B-SECONDARY MEDICO MEDIPLUS MEGA LIFE AND HEALTH INSURANCE MHEALTH MEDICAL CLAIMS MOAA ADMINISTRATORS MONUMENTAL LIFE INSURANCE MULTI PLAN PPO MUTUAL OF OMAHA NAHGA CLAIM SERVICES NALC HEALTH BENEFIT PLAN NATIONAL CLAIM SERVICES NEIHBP NEW HAMPSHIRE INS CO OPERATING ENGINEERS HEALTH AND WELFARE FUND OPTIMA HEALTH INS CO OPTUMHEALTH VISION OXFORD HEALTH PLANS PACIFICSOURCE HEALTH PLANS PAI PALMETTO GBA/NATIONAL SUPPLIER CLEARINGHOUSE PALMETTO GBA/RAILROAD MEDICARE PEARCE ADMINISTRATORS PHYSICIANS MUTUAL PPOPLUS LLC PRINCIPLE LIFE INSURANCE COMPANY SAMBA HEALTH BENEFIT PLAN SEAFARERS HEALTH AND BENEFITS PLAN SECURE HORIZONS SELF PAY SHEETMETAL WORKERS HEALTHPLAN SHEFFIELD RISK MANAGEMENT SIGHT SAVERS OF ALABAMA SMITH ADMINISTRATORS SMW+ SNL DBA BENEFIT MANAGEMENT SERVICE SOUTHLAND NATIONAL INS STATE FARM HEALTH INS STRATEGIC RESOURCE COMPANY SUPERIOR VISION SERVICE TEAM STAR THE HARTFORD THE LOOMIS COMPANY TIME INSURANCE CO./WEB MD TRANS CHOICE PLUS TRANSAMERICA LIFE INS TRICARE FOR LIFE TRICARE PRIME TRICARE STANDARD TRICARE WEST REGION UMR UMR CLAIMS UNICARE UNICARE STATE INDEMNITY PLAN UNITED AMERICAN INS. CO. UNITED HEALTH CARE-GA UNITED HEALTH CARE-TX UNITED HEALTH CARE-UT UNITED HEALTHCARE INTERNATIONAL UNITED HEALTHCARE STUDENT RESOURCES UNITED MEDICAL RESOURCES INC USA GASTROENTEROLOGY HERRERA MD VISION SERVICES PLAN VIVA HEALTH/CLAIMS DEPARTMENT VIVA MEDICARE PLUS VOCATIONAL REHABILITATION WAUSAU BENEFITS WEB-TPA WELLNET HEALTHCARE WHETSTONE BENEFIT ASMINISTRATORS Woodman of the World
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/MEDICARE COMPLETE AARP/UNITED HEALTHCARE CLAIM DIVISION ADVANTRA FREEDOM AETNA AETNA HEALTH AETNA LIFE INSURANCE COMPANY AHS STATE NETWORK AIG CLAIM SERVICES ALFA INSURANCE ALLIANT HEALTH PLAN, INC. ALLIED BENEFITS ALLSTATE CLAIMS ALTERNATIVE INSURANCE RESOURCES INC ALWAYS CARE BENEFITS INC AMA INSURANCE AGENCY AMERICAN PUBLIC LIFE AMERISAFE APPALACHIAN PIPELINE APWU HEALTH PLAN ASI Assurant Health ASSURANT HEALTH AVMA GROUP HEALTH AND LIFE INSURANCE TRUST BALL STATE UNIVERSITY BANKERS LIFE BANKERS LIFE AND CASUALTY BEECH STREET BENEFIT MANGEMENT SERVICE BERKLEY RISK ADMIN BLOCK VISION BLUE BELL HEALTH BENEFITS BLUE CROSS BLUE SHIELD BMS BOILERMAKERS BOILERMAKERS VISION CARPENTERS H&W/CMR CBS INC CENTRAL STATES SOUTHEAST CHAMP VA CHESTERFIELD RESOURCES CHOUEST GROUP HEALTH PLAN PPOPLUS, LLC CIGNA CIGNA GOVERNMENT SERVICES CIGNA/SAMBA HEALTH COMPBENEFITS-HUMANA CONSOLIDATED HEALTH PLANS CONTINENTAL LIFE CORPORATE BENEFITS SERVICE CORROSION MONOTORING DAUPHIN ISLAND VOL FIRE DEPT DEANS SCRAP METAL DEFINITY HEALTH Encompass Insurance EPS FAMILY LIFE INSURANCE COMPANY FIRST HEALTH NETWORK FISERV HEALTH FOX-EVERETT INC. GALLAGHER BASSETT SERVICES INC GE LIFE AND ANNUITY ASSURANCE CO. GEHA PPO USA GHI GILSBAR INC GLOBAL MEDICAL MANAGEMENT INC GOLDEN RULE INSURANCE COMPANY GREAT WEST HEALTHCARE GROUP ADMINISTRATORS LTD. GROUP AND PENSION ADMINSITRATORS INC GROUP RESOURCES INC GUARDIAN GROUP CLAIMS GULF HEALTH PLAN PPO-AIR INC. HEALTH NET MEDICARE ADVANTAGE HEALTHEOS HEALTHSCOPE INS HEALTHSMART HEALTHSPRING CLAIMS HIGHMARK BENEFITS HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY HTH WORLDWIDE INSURANCE SERVICES HTH/ AETNA GLOBAL BENEFITS HUMANA JESUIT HEALTH TRUST HMSR-CHRISTIAN BROTHERS SERVIC KEY BENEFIT ADMINSTRATORS LIONS CLUB LOYAL AMERICAN LIFE INS CO MAIL HANDLERS BENEFIT PLAN MARQUETTA NATIONAL LIFE INS./TODAY'S OPTION MEDICAL MUTUAL MEDICARE PART B MEDICARE PART B-SECONDARY MEDICO MEDIPLUS MEGA LIFE AND HEALTH INSURANCE MHEALTH MEDICAL CLAIMS MOAA ADMINISTRATORS MONUMENTAL LIFE INSURANCE MULTI PLAN PPO MUTUAL OF OMAHA NAHGA CLAIM SERVICES NALC HEALTH BENEFIT PLAN NATIONAL CLAIM SERVICES NEIHBP NEW HAMPSHIRE INS CO OPERATING ENGINEERS HEALTH AND WELFARE FUND OPTIMA HEALTH INS CO OPTUMHEALTH VISION OXFORD HEALTH PLANS PACIFICSOURCE HEALTH PLANS PAI PALMETTO GBA/NATIONAL SUPPLIER CLEARINGHOUSE PALMETTO GBA/RAILROAD MEDICARE PEARCE ADMINISTRATORS PHYSICIANS MUTUAL PPOPLUS LLC PRINCIPLE LIFE INSURANCE COMPANY SAMBA HEALTH BENEFIT PLAN SEAFARERS HEALTH AND BENEFITS PLAN SECURE HORIZONS SELF PAY SHEETMETAL WORKERS HEALTHPLAN SHEFFIELD RISK MANAGEMENT SIGHT SAVERS OF ALABAMA SMITH ADMINISTRATORS SMW+ SNL DBA BENEFIT MANAGEMENT SERVICE SOUTHLAND NATIONAL INS STATE FARM HEALTH INS STRATEGIC RESOURCE COMPANY SUPERIOR VISION SERVICE TEAM STAR THE HARTFORD THE LOOMIS COMPANY TIME INSURANCE CO./WEB MD TRANS CHOICE PLUS TRANSAMERICA LIFE INS TRICARE FOR LIFE TRICARE PRIME TRICARE STANDARD TRICARE WEST REGION UMR UMR CLAIMS UNICARE UNICARE STATE INDEMNITY PLAN UNITED AMERICAN INS. CO. UNITED HEALTH CARE-GA UNITED HEALTH CARE-TX UNITED HEALTH CARE-UT UNITED HEALTHCARE INTERNATIONAL UNITED HEALTHCARE STUDENT RESOURCES UNITED MEDICAL RESOURCES INC USA GASTROENTEROLOGY HERRERA MD VISION SERVICES PLAN VIVA HEALTH/CLAIMS DEPARTMENT VIVA MEDICARE PLUS VOCATIONAL REHABILITATION WAUSAU BENEFITS WEB-TPA WELLNET HEALTHCARE WHETSTONE BENEFIT ASMINISTRATORS Woodman of the World
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 Insurance

Insurance Information

Insurance Name:	None AARP/MEDICARE COMPLETE AARP/UNITED HEALTHCARE CLAIM DIVISION ADVANTRA FREEDOM AETNA AETNA HEALTH AETNA LIFE INSURANCE COMPANY AHS STATE NETWORK AIG CLAIM SERVICES ALFA INSURANCE ALLIANT HEALTH PLAN, INC. ALLIED BENEFITS ALLSTATE CLAIMS ALTERNATIVE INSURANCE RESOURCES INC ALWAYS CARE BENEFITS INC AMA INSURANCE AGENCY AMERICAN PUBLIC LIFE AMERISAFE APPALACHIAN PIPELINE APWU HEALTH PLAN ASI Assurant Health ASSURANT HEALTH AVMA GROUP HEALTH AND LIFE INSURANCE TRUST BALL STATE UNIVERSITY BANKERS LIFE BANKERS LIFE AND CASUALTY BEECH STREET BENEFIT MANGEMENT SERVICE BERKLEY RISK ADMIN BLOCK VISION BLUE BELL HEALTH BENEFITS BLUE CROSS BLUE SHIELD BMS BOILERMAKERS BOILERMAKERS VISION CARPENTERS H&W/CMR CBS INC CENTRAL STATES SOUTHEAST CHAMP VA CHESTERFIELD RESOURCES CHOUEST GROUP HEALTH PLAN PPOPLUS, LLC CIGNA CIGNA GOVERNMENT SERVICES CIGNA/SAMBA HEALTH COMPBENEFITS-HUMANA CONSOLIDATED HEALTH PLANS CONTINENTAL LIFE CORPORATE BENEFITS SERVICE CORROSION MONOTORING DAUPHIN ISLAND VOL FIRE DEPT DEANS SCRAP METAL DEFINITY HEALTH Encompass Insurance EPS FAMILY LIFE INSURANCE COMPANY FIRST HEALTH NETWORK FISERV HEALTH FOX-EVERETT INC. GALLAGHER BASSETT SERVICES INC GE LIFE AND ANNUITY ASSURANCE CO. GEHA PPO USA GHI GILSBAR INC GLOBAL MEDICAL MANAGEMENT INC GOLDEN RULE INSURANCE COMPANY GREAT WEST HEALTHCARE GROUP ADMINISTRATORS LTD. GROUP AND PENSION ADMINSITRATORS INC GROUP RESOURCES INC GUARDIAN GROUP CLAIMS GULF HEALTH PLAN PPO-AIR INC. HEALTH NET MEDICARE ADVANTAGE HEALTHEOS HEALTHSCOPE INS HEALTHSMART HEALTHSPRING CLAIMS HIGHMARK BENEFITS HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY HTH WORLDWIDE INSURANCE SERVICES HTH/ AETNA GLOBAL BENEFITS HUMANA JESUIT HEALTH TRUST HMSR-CHRISTIAN BROTHERS SERVIC KEY BENEFIT ADMINSTRATORS LIONS CLUB LOYAL AMERICAN LIFE INS CO MAIL HANDLERS BENEFIT PLAN MARQUETTA NATIONAL LIFE INS./TODAY'S OPTION MEDICAL MUTUAL MEDICARE PART B MEDICARE PART B-SECONDARY MEDICO MEDIPLUS MEGA LIFE AND HEALTH INSURANCE MHEALTH MEDICAL CLAIMS MOAA ADMINISTRATORS MONUMENTAL LIFE INSURANCE MULTI PLAN PPO MUTUAL OF OMAHA NAHGA CLAIM SERVICES NALC HEALTH BENEFIT PLAN NATIONAL CLAIM SERVICES NEIHBP NEW HAMPSHIRE INS CO OPERATING ENGINEERS HEALTH AND WELFARE FUND OPTIMA HEALTH INS CO OPTUMHEALTH VISION OXFORD HEALTH PLANS PACIFICSOURCE HEALTH PLANS PAI PALMETTO GBA/NATIONAL SUPPLIER CLEARINGHOUSE PALMETTO GBA/RAILROAD MEDICARE PEARCE ADMINISTRATORS PHYSICIANS MUTUAL PPOPLUS LLC PRINCIPLE LIFE INSURANCE COMPANY SAMBA HEALTH BENEFIT PLAN SEAFARERS HEALTH AND BENEFITS PLAN SECURE HORIZONS SELF PAY SHEETMETAL WORKERS HEALTHPLAN SHEFFIELD RISK MANAGEMENT SIGHT SAVERS OF ALABAMA SMITH ADMINISTRATORS SMW+ SNL DBA BENEFIT MANAGEMENT SERVICE SOUTHLAND NATIONAL INS STATE FARM HEALTH INS STRATEGIC RESOURCE COMPANY SUPERIOR VISION SERVICE TEAM STAR THE HARTFORD THE LOOMIS COMPANY TIME INSURANCE CO./WEB MD TRANS CHOICE PLUS TRANSAMERICA LIFE INS TRICARE FOR LIFE TRICARE PRIME TRICARE STANDARD TRICARE WEST REGION UMR UMR CLAIMS UNICARE UNICARE STATE INDEMNITY PLAN UNITED AMERICAN INS. CO. UNITED HEALTH CARE-GA UNITED HEALTH CARE-TX UNITED HEALTH CARE-UT UNITED HEALTHCARE INTERNATIONAL UNITED HEALTHCARE STUDENT RESOURCES UNITED MEDICAL RESOURCES INC USA GASTROENTEROLOGY HERRERA MD VISION SERVICES PLAN VIVA HEALTH/CLAIMS DEPARTMENT VIVA MEDICARE PLUS VOCATIONAL REHABILITATION WAUSAU BENEFITS WEB-TPA WELLNET HEALTHCARE WHETSTONE BENEFIT ASMINISTRATORS Woodman of the World
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 Medical

Insurance Information

Insurance Name:	None AARP/MEDICARE COMPLETE AARP/UNITED HEALTHCARE CLAIM DIVISION ADVANTRA FREEDOM AETNA AETNA HEALTH AETNA LIFE INSURANCE COMPANY AHS STATE NETWORK AIG CLAIM SERVICES ALFA INSURANCE ALLIANT HEALTH PLAN, INC. ALLIED BENEFITS ALLSTATE CLAIMS ALTERNATIVE INSURANCE RESOURCES INC ALWAYS CARE BENEFITS INC AMA INSURANCE AGENCY AMERICAN PUBLIC LIFE AMERISAFE APPALACHIAN PIPELINE APWU HEALTH PLAN ASI Assurant Health ASSURANT HEALTH AVMA GROUP HEALTH AND LIFE INSURANCE TRUST BALL STATE UNIVERSITY BANKERS LIFE BANKERS LIFE AND CASUALTY BEECH STREET BENEFIT MANGEMENT SERVICE BERKLEY RISK ADMIN BLOCK VISION BLUE BELL HEALTH BENEFITS BLUE CROSS BLUE SHIELD BMS BOILERMAKERS BOILERMAKERS VISION CARPENTERS H&W/CMR CBS INC CENTRAL STATES SOUTHEAST CHAMP VA CHESTERFIELD RESOURCES CHOUEST GROUP HEALTH PLAN PPOPLUS, LLC CIGNA CIGNA GOVERNMENT SERVICES CIGNA/SAMBA HEALTH COMPBENEFITS-HUMANA CONSOLIDATED HEALTH PLANS CONTINENTAL LIFE CORPORATE BENEFITS SERVICE CORROSION MONOTORING DAUPHIN ISLAND VOL FIRE DEPT DEANS SCRAP METAL DEFINITY HEALTH Encompass Insurance EPS FAMILY LIFE INSURANCE COMPANY FIRST HEALTH NETWORK FISERV HEALTH FOX-EVERETT INC. GALLAGHER BASSETT SERVICES INC GE LIFE AND ANNUITY ASSURANCE CO. GEHA PPO USA GHI GILSBAR INC GLOBAL MEDICAL MANAGEMENT INC GOLDEN RULE INSURANCE COMPANY GREAT WEST HEALTHCARE GROUP ADMINISTRATORS LTD. GROUP AND PENSION ADMINSITRATORS INC GROUP RESOURCES INC GUARDIAN GROUP CLAIMS GULF HEALTH PLAN PPO-AIR INC. HEALTH NET MEDICARE ADVANTAGE HEALTHEOS HEALTHSCOPE INS HEALTHSMART HEALTHSPRING CLAIMS HIGHMARK BENEFITS HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY HTH WORLDWIDE INSURANCE SERVICES HTH/ AETNA GLOBAL BENEFITS HUMANA JESUIT HEALTH TRUST HMSR-CHRISTIAN BROTHERS SERVIC KEY BENEFIT ADMINSTRATORS LIONS CLUB LOYAL AMERICAN LIFE INS CO MAIL HANDLERS BENEFIT PLAN MARQUETTA NATIONAL LIFE INS./TODAY'S OPTION MEDICAL MUTUAL MEDICARE PART B MEDICARE PART B-SECONDARY MEDICO MEDIPLUS MEGA LIFE AND HEALTH INSURANCE MHEALTH MEDICAL CLAIMS MOAA ADMINISTRATORS MONUMENTAL LIFE INSURANCE MULTI PLAN PPO MUTUAL OF OMAHA NAHGA CLAIM SERVICES NALC HEALTH BENEFIT PLAN NATIONAL CLAIM SERVICES NEIHBP NEW HAMPSHIRE INS CO OPERATING ENGINEERS HEALTH AND WELFARE FUND OPTIMA HEALTH INS CO OPTUMHEALTH VISION OXFORD HEALTH PLANS PACIFICSOURCE HEALTH PLANS PAI PALMETTO GBA/NATIONAL SUPPLIER CLEARINGHOUSE PALMETTO GBA/RAILROAD MEDICARE PEARCE ADMINISTRATORS PHYSICIANS MUTUAL PPOPLUS LLC PRINCIPLE LIFE INSURANCE COMPANY SAMBA HEALTH BENEFIT PLAN SEAFARERS HEALTH AND BENEFITS PLAN SECURE HORIZONS SELF PAY SHEETMETAL WORKERS HEALTHPLAN SHEFFIELD RISK MANAGEMENT SIGHT SAVERS OF ALABAMA SMITH ADMINISTRATORS SMW+ SNL DBA BENEFIT MANAGEMENT SERVICE SOUTHLAND NATIONAL INS STATE FARM HEALTH INS STRATEGIC RESOURCE COMPANY SUPERIOR VISION SERVICE TEAM STAR THE HARTFORD THE LOOMIS COMPANY TIME INSURANCE CO./WEB MD TRANS CHOICE PLUS TRANSAMERICA LIFE INS TRICARE FOR LIFE TRICARE PRIME TRICARE STANDARD TRICARE WEST REGION UMR UMR CLAIMS UNICARE UNICARE STATE INDEMNITY PLAN UNITED AMERICAN INS. CO. UNITED HEALTH CARE-GA UNITED HEALTH CARE-TX UNITED HEALTH CARE-UT UNITED HEALTHCARE INTERNATIONAL UNITED HEALTHCARE STUDENT RESOURCES UNITED MEDICAL RESOURCES INC USA GASTROENTEROLOGY HERRERA MD VISION SERVICES PLAN VIVA HEALTH/CLAIMS DEPARTMENT VIVA MEDICARE PLUS VOCATIONAL REHABILITATION WAUSAU BENEFITS WEB-TPA WELLNET HEALTHCARE WHETSTONE BENEFIT ASMINISTRATORS Woodman of the World
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:

Fourth

Insurance Information

Insurance Name:	None AARP/MEDICARE COMPLETE AARP/UNITED HEALTHCARE CLAIM DIVISION ADVANTRA FREEDOM AETNA AETNA HEALTH AETNA LIFE INSURANCE COMPANY AHS STATE NETWORK AIG CLAIM SERVICES ALFA INSURANCE ALLIANT HEALTH PLAN, INC. ALLIED BENEFITS ALLSTATE CLAIMS ALTERNATIVE INSURANCE RESOURCES INC ALWAYS CARE BENEFITS INC AMA INSURANCE AGENCY AMERICAN PUBLIC LIFE AMERISAFE APPALACHIAN PIPELINE APWU HEALTH PLAN ASI Assurant Health ASSURANT HEALTH AVMA GROUP HEALTH AND LIFE INSURANCE TRUST BALL STATE UNIVERSITY BANKERS LIFE BANKERS LIFE AND CASUALTY BEECH STREET BENEFIT MANGEMENT SERVICE BERKLEY RISK ADMIN BLOCK VISION BLUE BELL HEALTH BENEFITS BLUE CROSS BLUE SHIELD BMS BOILERMAKERS BOILERMAKERS VISION CARPENTERS H&W/CMR CBS INC CENTRAL STATES SOUTHEAST CHAMP VA CHESTERFIELD RESOURCES CHOUEST GROUP HEALTH PLAN PPOPLUS, LLC CIGNA CIGNA GOVERNMENT SERVICES CIGNA/SAMBA HEALTH COMPBENEFITS-HUMANA CONSOLIDATED HEALTH PLANS CONTINENTAL LIFE CORPORATE BENEFITS SERVICE CORROSION MONOTORING DAUPHIN ISLAND VOL FIRE DEPT DEANS SCRAP METAL DEFINITY HEALTH Encompass Insurance EPS FAMILY LIFE INSURANCE COMPANY FIRST HEALTH NETWORK FISERV HEALTH FOX-EVERETT INC. GALLAGHER BASSETT SERVICES INC GE LIFE AND ANNUITY ASSURANCE CO. GEHA PPO USA GHI GILSBAR INC GLOBAL MEDICAL MANAGEMENT INC GOLDEN RULE INSURANCE COMPANY GREAT WEST HEALTHCARE GROUP ADMINISTRATORS LTD. GROUP AND PENSION ADMINSITRATORS INC GROUP RESOURCES INC GUARDIAN GROUP CLAIMS GULF HEALTH PLAN PPO-AIR INC. HEALTH NET MEDICARE ADVANTAGE HEALTHEOS HEALTHSCOPE INS HEALTHSMART HEALTHSPRING CLAIMS HIGHMARK BENEFITS HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY HTH WORLDWIDE INSURANCE SERVICES HTH/ AETNA GLOBAL BENEFITS HUMANA JESUIT HEALTH TRUST HMSR-CHRISTIAN BROTHERS SERVIC KEY BENEFIT ADMINSTRATORS LIONS CLUB LOYAL AMERICAN LIFE INS CO MAIL HANDLERS BENEFIT PLAN MARQUETTA NATIONAL LIFE INS./TODAY'S OPTION MEDICAL MUTUAL MEDICARE PART B MEDICARE PART B-SECONDARY MEDICO MEDIPLUS MEGA LIFE AND HEALTH INSURANCE MHEALTH MEDICAL CLAIMS MOAA ADMINISTRATORS MONUMENTAL LIFE INSURANCE MULTI PLAN PPO MUTUAL OF OMAHA NAHGA CLAIM SERVICES NALC HEALTH BENEFIT PLAN NATIONAL CLAIM SERVICES NEIHBP NEW HAMPSHIRE INS CO OPERATING ENGINEERS HEALTH AND WELFARE FUND OPTIMA HEALTH INS CO OPTUMHEALTH VISION OXFORD HEALTH PLANS PACIFICSOURCE HEALTH PLANS PAI PALMETTO GBA/NATIONAL SUPPLIER CLEARINGHOUSE PALMETTO GBA/RAILROAD MEDICARE PEARCE ADMINISTRATORS PHYSICIANS MUTUAL PPOPLUS LLC PRINCIPLE LIFE INSURANCE COMPANY SAMBA HEALTH BENEFIT PLAN SEAFARERS HEALTH AND BENEFITS PLAN SECURE HORIZONS SELF PAY SHEETMETAL WORKERS HEALTHPLAN SHEFFIELD RISK MANAGEMENT SIGHT SAVERS OF ALABAMA SMITH ADMINISTRATORS SMW+ SNL DBA BENEFIT MANAGEMENT SERVICE SOUTHLAND NATIONAL INS STATE FARM HEALTH INS STRATEGIC RESOURCE COMPANY SUPERIOR VISION SERVICE TEAM STAR THE HARTFORD THE LOOMIS COMPANY TIME INSURANCE CO./WEB MD TRANS CHOICE PLUS TRANSAMERICA LIFE INS TRICARE FOR LIFE TRICARE PRIME TRICARE STANDARD TRICARE WEST REGION UMR UMR CLAIMS UNICARE UNICARE STATE INDEMNITY PLAN UNITED AMERICAN INS. CO. UNITED HEALTH CARE-GA UNITED HEALTH CARE-TX UNITED HEALTH CARE-UT UNITED HEALTHCARE INTERNATIONAL UNITED HEALTHCARE STUDENT RESOURCES UNITED MEDICAL RESOURCES INC USA GASTROENTEROLOGY HERRERA MD VISION SERVICES PLAN VIVA HEALTH/CLAIMS DEPARTMENT VIVA MEDICARE PLUS VOCATIONAL REHABILITATION WAUSAU BENEFITS WEB-TPA WELLNET HEALTHCARE WHETSTONE BENEFIT ASMINISTRATORS Woodman of the World
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

Concern/Reason for visit:  distance vision blurry near vision blurry vision blurry distance and near red eye pain in eye loss of vision injury to eye needs new glasses wants to be fitted for contacts itching burning stinging dry eyes Diabetic eye exam
Date of Injury/ Sec Complaints:
Reffered by:   Reffering Doctor:   Family Who We Also See:
Are you interested in contact lenses?  Yes No  Have you ever worn contact lenses? Wear Them Now Yes No Stopped Wearing  Interested in refractive surgery (LASIX)? No Yes
 
OCULAR HISTORY
Last eye exam: 1 year 2 years 3 years Doctor:  Doesn't Remember Never Dr. Murray Glusman

Eye Surgery	None Cataracts removed LASIK Retinal laser Eye lid	Glaucoma	No Yes
Eye Injury	None	Cataracts	No Yes
Eye Infection	None Pink eye Corneal Ulcer	Lazy Eye	No Right eye Left eye
Eye Drops	None Artificial tears Redness reliever Restasis Glaucoma Meds unknown	Macular Degeneration	No Yes
Glasses	Yes No In the past	Retinal Detachment	No Yes
Contacts	No Yes In the past	Other Retinopathy	No Hole Nevus RP Diabetic Retinopathy PVD
Itch	No Yes	Headaches	No Yes
Burn	No Yes	Glare	No Yes
Tear	No Yes	Eyestrain	No Yes with near work with distance work at computer
Flashes	No Yes	Eye Pain	No Yes
Diplopia	No Diplopia In one eye	FBS	No Yes
Floaters	No Yes longstanding/no change Yes	Photosensitive	No Yes
Redness	No Yes OD Only Yes OS Only Yes Both	Discharge	No Yellow Green Clear Stringy
Eyelid Droop	No Yes	Eyelid Edema	No Yes

 

 

 

 

 

 

 



Any additional notes:

FAMILY OCULAR HISTORY 

Glaucoma	No Mother Father Sibling Grandparent
Cataracts	No Father Mother Siblings Grandparent
Macular Degeneration	No Grandparent Mother Father Siblings
Crossed / Lazy Eye	No Parents Siblings Grandparent
Retinal Detachment	No Parents Siblings Grandparent

 

 

 

 

CURRENT CONTACT LENSES 
Brand:  Disposal: when irritate 2 weeks monthly daily weekly yearly 2-4 weeks 4-6 weeks 2-3 months  Wear Time: 8 - 10 Hours All day Extended Occasionally EW 3-4 x/wk EW 2-3 x/wk for sports only  Cleaner: Optifree Clear Care Boston Renu BioTru Saline only  Happy with current CL? Yes No Dry Blurry uncomfortable cause redness move too much want daily disposable want extended wear want color want BF's
    
NOTES:

CURRENT MEDICAL HISTORY

Do you have any of the following conditions?

Diabetes:   NO YES Heart: NO YES In past Stroke: NO YES Arthritis: NO YES In past Cancer:  No Yes In past Other/STD: NO
Injuries, Surgeries, Hospitalization:
Notes:
Pregnant Or Nursing: No Yes Unsure  Primary Care Physcian:   Last Visit: 1 week 1 month 3 months 6 months 1 year 2 years
Vitamins:
Prescription Medication (please select any that you are on below)
Actos Acyclovir Adderall Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Furosamide Glucophage Glyburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methlyprednisolone MS Contin Nasacort None Novalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracycline Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft Actos Acyclovir Adderall Albuterol Allegra ALtase Amaryl Amiodarone Amoxycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Detrol Diclofenac Diovan Dpakote Effexor Flomax Flonase Furosamide Glucophage Glyburide HCTZ Humulin Hydrocorisone Lasix Levaquin Lipitor Lortab Metformin Methlyprednisolone MS Contin Nasacort Novalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonis Proventil Prozac Ritalin Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft Actos Acyclovir Adderall Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin Atenlol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Furosamide Glucophage Glyburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methlyprednisolone MS Contin Nasacort Novalog Oxycodone Pepecid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Xantac Zestril Zoloft Actos Acyclovir Adderall Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Furosamide Glucophage Glylburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methlyprednisolone MS Contin Nasacort NOvalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft Actos ACyclovir Adderall Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin Atenolol Augmentin Bactoban Buspar Captopril Carbamazepine Cefzil Celebrex Clonidin Coumadin Cozar Cretor Depakote Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax FLonase Furosamide Glucophage Glyburide HCTZ Humlin Hyrdocortisone Lasix Levaquin Lipitor Lortab Metformin Methlprednisolone MS Contin Nasacort Novalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft Actos Acyclovir Adderall Albuterol Allegra Altase Amaryl Amiodarone Amocycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Furosamide Glucophage Glyburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methlyprednisolone MS Contin Nasacort Novalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozc Ritalin Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft
Actos Acyclovir Adderall Albuterol Allegra Altase Amaryle Amiodarone Amoxycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Divan Efeexor Flomax Flonase Furosamide Glucophage Glyburide HCTZ Humlin Hyrdrocortisone Levaquin Lipitor Lortab Metformin Methlyprednisolone MS Contin NAsacort Novalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracyclin topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft Actos Acyclovir Adderalll Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Flonase Furosamide Glucophage Glyburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methylprednisolone MS Contin Nasacort Nasacort Novalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft Actos Acyclovir Adderall Albuterol Allegra Altase Amaryl Amiodarone Amocycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Cipro Clebrex Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Flomax Flonase Furosamide Glucophage Glyburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methylprednisolone MS Contin Nasacort Novalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracyclin Topamax Valium Welbutrin Xanax Zantac Zestril Zoloft ACtos Acyclovir Adderall Albuterol Allegra ALtase Amaryl Amidarone Amoxycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Furosamide Glucophage Glyburide HCTZ Humlin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methylprednisolone MS Contin Nasacort Novalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft Actos Acyclovir Adderall Albuterol Allegra ALtase Amaryl Amiodarone Amoxycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Furosamide Glucophage Glyburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methlyprednisolone MS Contin Nasacort Novalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft Actos Acyclovir Adderall Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Furosamide Glucophage Glyburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methylpredisolone MS Contin Nasacort Novalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singular Synthroid Tetracyclin Topamax Valium Wellbutrin Xanax Zantac Zestril Zoloft
List Drug Allergies:   
List Over the Counter:
Eye drop 1: None Visine Clear Eyes Systane Blink Rewetting drops Generic artificial tears Refresh Genteal Gel Restasis Eye Drop 2:  Eye Drop 3:
Other Eye Medications:  
Notes:

 
FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other

SOCIAL HISTORY 
Occupation: Hobbies: Astronomy Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint None Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking 
Smoking Status: No Yes In Past Type: None Cigaretts Chewing Tobacco How Long:  How much: 1/2 pack / day 1 pack / day
Alcohol use: No Yes Occasionally Socially Type: None Beer Wine Hard Liquor How Long:   How much:
Illegal Drugs:  No Yes Type:  How Long:
Marital Status: Single Married Separated Divorced Widowed Children:  Grand Children:   Great Grand Children:

REVIEW OF SYSTEMS: DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

GENERAL: Fever, weight loss, weight gain, fatigue?	None Negative
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat	None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease	None High BP Surgery Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD	None Asthma Bronchitis Emphysema COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence	None painful urination frequent urination impotence yellow jaundice
MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury	None joint pain stiffness swelling cramps arthritis
SKIN: growths, rashes, acne	None pimples, warts growths rash
NEUROLOGICAL: Headaches, migraines, seizures	None numbness, paralysis headache seizures migraines
PSYCHIATRIC: Depression, Anxiety, Insomnia	None anxiety depression insomnia
ENDORCRINE: Thyroid, Diabetes	None diabetes hypothyroid hyperthoyroid
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
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux	None Diarrhea Constipation Ulcer Acid Reflux

 

 

 

 


 

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