New Patient Form

Demographics

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

Address:
City:		State/ZipCode	TX 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

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. Anker, Darlene	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Address

City	State	ZipCode
	TX 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

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP Aetna Aetna MedAdvantage Anthem Blue Cross Blue Cross Blue Shield Carpenters Health & Security Trust CAS CAS CHAMPVA-HAC Cigna Community Health Plan of WA Department of Labor & Industries DSHS EBMS Essence Eyemed First Choice GEHA Great West Group Health Highmark Health Options HMA HMSA Humana Kaiser Permanente Labor & Industries Lifewise Lummi Tribe Masters Mates & Pilots - Cigna Medi-Share Medicare of Washington Meritain Health Miscellaneous Ins Molina Mutual of Omaha Mutual of Omaha NBN Nooksack Indian Tribe Northwest Physicians Network Northwest Plumbing & Pipefitters NWA (Teamsters) Optum PREMERA Premera MedAdvantage Railroad Medicare Regence Regence Group Administrators Regence MedAdvantage Shasta Shenandoah Life SIMPLE Sound Health & Wellness Trust Soundpath Health Sterling TriCare for Life TriCare WEST Triwest VA CCN Trusteed Plans Service Corporation UMR United American United Healthcare United HealthCare MedAdvantage United HealthCare Military and Veterans United World Life Ins. Co USAA VSP VSP Molina WebTPA WPAS
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 Aetna MedAdvantage Anthem Blue Cross Blue Cross Blue Shield Carpenters Health & Security Trust CAS CAS CHAMPVA-HAC Cigna Community Health Plan of WA Department of Labor & Industries DSHS EBMS Essence Eyemed First Choice GEHA Great West Group Health Highmark Health Options HMA HMSA Humana Kaiser Permanente Labor & Industries Lifewise Lummi Tribe Masters Mates & Pilots - Cigna Medi-Share Medicare of Washington Meritain Health Miscellaneous Ins Molina Mutual of Omaha Mutual of Omaha NBN Nooksack Indian Tribe Northwest Physicians Network Northwest Plumbing & Pipefitters NWA (Teamsters) Optum PREMERA Premera MedAdvantage Railroad Medicare Regence Regence Group Administrators Regence MedAdvantage Shasta Shenandoah Life SIMPLE Sound Health & Wellness Trust Soundpath Health Sterling TriCare for Life TriCare WEST Triwest VA CCN Trusteed Plans Service Corporation UMR United American United Healthcare United HealthCare MedAdvantage United HealthCare Military and Veterans United World Life Ins. Co USAA VSP VSP Molina WebTPA WPAS
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 Aetna MedAdvantage Anthem Blue Cross Blue Cross Blue Shield Carpenters Health & Security Trust CAS CAS CHAMPVA-HAC Cigna Community Health Plan of WA Department of Labor & Industries DSHS EBMS Essence Eyemed First Choice GEHA Great West Group Health Highmark Health Options HMA HMSA Humana Kaiser Permanente Labor & Industries Lifewise Lummi Tribe Masters Mates & Pilots - Cigna Medi-Share Medicare of Washington Meritain Health Miscellaneous Ins Molina Mutual of Omaha Mutual of Omaha NBN Nooksack Indian Tribe Northwest Physicians Network Northwest Plumbing & Pipefitters NWA (Teamsters) Optum PREMERA Premera MedAdvantage Railroad Medicare Regence Regence Group Administrators Regence MedAdvantage Shasta Shenandoah Life SIMPLE Sound Health & Wellness Trust Soundpath Health Sterling TriCare for Life TriCare WEST Triwest VA CCN Trusteed Plans Service Corporation UMR United American United Healthcare United HealthCare MedAdvantage United HealthCare Military and Veterans United World Life Ins. Co USAA VSP VSP Molina WebTPA WPAS
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

PATIENT MEDICAL HISTORY
Please select any problems you may have from the drop downs below.
Good health Arthritis Asthma Diabetes HBP Headaches Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Disease Back Problems Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Athritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems Diabetes HBP Heart disease Cancer Arthritis Lupus Kidney Thyroid Back Problems
Please list any Injuries, Surgeries, Hospitalization
Pregnant Or Nursing: No Yes Unsure Recent Tetanus Shot: Yes No
Medications:
Primary Care Physcian: Last Visit: 1 week 1 month 3 months 6 months 1 year 2 years Reason For Visit: Check up Annual
List any Vitamins you take:
Please list any over the Counter medications:
Please list your current Prescription Medications: No Current Medications
Please list all drug allergies: No Known Drug Allergies

FAMILY MEDICAL HISTORY
Do you have a history of any of the following in your family? (Please select from the drop downs below.)
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid
Hobbies:
Smoking Status: Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked Type: None Cigarettes Chewing Tobacco How Long:
Alcohol: No Yes Occasionally Socially Type: None Beer Wine Hard Liquor How Long:
Illegal Drugs: No Yes Type: How Long: STD: None Gonorrhea Syphilis Hepatitis HIV TB

PATIENT OCULAR HISTORY
Please select if you have had any of the following: Itching Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders None
Please select your current Eye Meds: None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink
Last Eye Doctor: Last Eye Exam: 1 year 2 years 3 years over 3 years
 
FAMILY OCULAR HISTORY

Glaucoma: No Parents Sibling Grandparent Crossed / Lazy: No Parents Siblings Grandparent Retinal Detach: No Parents Siblings Grandparent Macular Degeneration: No Parents Siblings Grandparent Cataracts: No Parents Siblings Grandparent

Primary Vision Correction:  None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA  Planning to get new glasses? Yes No  Back up specs? Yes No

Type of CLs worn in past: None Disposable Conventional Colored RGP PMMA  Wear Time: 8 - 10 Hours All day Occ. Overnight Extended Cleaner: Optifree Clear Care Boston Renu Disposal: 2 weeks monthly daily weekly yearly

NOTES:

Preferred Language: English French German Spanish  Ethnicity:  Non Hispanic or Latino Hispanic or Latino  Race:  American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White
 

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

GENERAL: Fever, weight loss, weight gain, fatigue?
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

Submit / Patient Signatures

Click the submit button at the bottom of this tab to complete your forms and submit your information:

Financial Policy and Agreement

ClearView Eyecare, PLLC

Payment is due at time of service, unless prior arrangements have been made. Accepted forms of payment include cash, check, VISA, Mastercard, Discover and American Express.

Please notify us at least 24 hours in advance if you must change or cancel your appointment. By signing below, I understand and accept that repeated failure to extend this courtesy will result in an Exam Fee of $200 applied to my account, payable before any further services will be rendered.

I have read and understand the above financial policy. I agree that I am responsible for all charges incurred on my account. I also understand that ClearView Eyecare will not share my personal information without my permission and that I am able to request a complete copy of ClearView Eyecare's Notice of Privacy Practices.

I authorize ClearView Eyecare to contact me via phone, text or e-mail.

Print: Date:
Signature:


Insurance Assignment and Release:
If we are a participating provider, we will bill your insurance plan. If we bill your insurance, you are responsible for the co-pay and co-insurance amounts specified by your insurance at the time of service. I understand that I will be billed for any services not covered or for any charges deemed patient responsibility by my insurance plan. Initial

As a courtesy to you, our staff has done their best to verify your coverage, but as it is the patient's ultimate responsibility to verify coverage and eligibility, any estimate of patient amounts due are truly estimates. I understand that it is my responsibility to verify insurance coverage, and any benefit quoted by the staff at ClearView Eyecare is only an estimate of my coverage. Initial

Please note that we are providing a service when we file your claim. If a clean claim is not paid after 90 days from the date of service, we will transfer the balance to you, and you will be responsible for any outstanding charges on your account. I understand that I am ultimately responsible for charges even with insurance. Initial

I authorize my insurance benefits to be paid directly to ClearView Eyecare. I understand that I am financially responsible for non-covered services and materials. Additionally, I authorized the doctor and staff at ClearView Eyecare to release any and all information required to process my claim.

Print: Date:
Signature:


HIPAA Compliance Patient Consent Form
To view the HIPPA document please click the link below, once you have read it make sure to come back to this page and sign below, Thank you!

View HIPAA Compliance Patient Consent Form

Print: Date:
Signature: