Snipes & Assoc. Patient Form

Demographics

Patient Information

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

Address: *
City: *		State/ZipCode *	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX 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	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Misc/Guardian		Drivers License #

Is the Billing Address Different?

Billing Information

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

Copy Address From Above
Address

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

Home Phone:
Work Phone:

Primary Medical

Insurance Information

Insurance Name:	None AARP/AAA AETNA Aetna Medicaid ALWAYS CARE BENEFITS,INC Ambetter: Managed Health Services Anthem BCBS Anthem BlueCross BlueShield Medicaid Avesis Third Party Administors, Inc. Baltas Vision Bankers Fidelity Baptist Health Plan Block Vision Blue Grass Family Health Boon Chapman ChampVA CHUBB Perennial Care Cigna International Cigna Medical Cigna Vision Colonial Life Insurance Combined Insurance Co. of America Coventry Care Davis Vision EBMS Eye Med Vision Care EyeQuest First Health Network HEALTH SMART BENEFITS SOLUTION,INC HealthSpan Humana Care Source Humana Medical Humana One Indiana Teamsters Health Benefits Fund IU Health Plans J.P. Farley Corporation JFP Bnefits Management Inc Johnson & Johnson (Vistakon) Kentucky Caresource Kentucky Health Cooperative KY Health Choices KY Laborers District Councel MEDICA UHC Medicaid MEDICAL MUTUAL Medicare Medico Medical Medico Vision MERCY HEALTH Meritain Health an Aetna Company Met Life Vision MHBP Omaha Optimed Health Plan Oxford Life Insurance Company Passport Health Plan Physicians Mutual Plumbers & Pipefitters Local 502 PREFERRED Principal Principal Life Insurance Company Priority PriorityHealth PriorityHealth HMO Reliance Standard Life SAMBA Federal Health Plan Southland Benefit Solutions, LLC Superior Vision TransAmerica Financial Life Ins Company Tri-Care for Life (Medicare Supplement) Tricare North Region Health Net Federal Services, Inc.- c/o PGBA, LLC/TRICARE Tricare Prime TriWest UMR United Healthcare United Healthcare ST unknown Veterans Affair Vision Care Plus (VCP) VSP Webster West Inc Wellcare
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 Supplement

Insurance Information

Insurance Name:	None AARP/AAA AETNA Aetna Medicaid ALWAYS CARE BENEFITS,INC Ambetter: Managed Health Services Anthem BCBS Anthem BlueCross BlueShield Medicaid Avesis Third Party Administors, Inc. Baltas Vision Bankers Fidelity Baptist Health Plan Block Vision Blue Grass Family Health Boon Chapman ChampVA CHUBB Perennial Care Cigna International Cigna Medical Cigna Vision Colonial Life Insurance Combined Insurance Co. of America Coventry Care Davis Vision EBMS Eye Med Vision Care EyeQuest First Health Network HEALTH SMART BENEFITS SOLUTION,INC HealthSpan Humana Care Source Humana Medical Humana One Indiana Teamsters Health Benefits Fund IU Health Plans J.P. Farley Corporation JFP Bnefits Management Inc Johnson & Johnson (Vistakon) Kentucky Caresource Kentucky Health Cooperative KY Health Choices KY Laborers District Councel MEDICA UHC Medicaid MEDICAL MUTUAL Medicare Medico Medical Medico Vision MERCY HEALTH Meritain Health an Aetna Company Met Life Vision MHBP Omaha Optimed Health Plan Oxford Life Insurance Company Passport Health Plan Physicians Mutual Plumbers & Pipefitters Local 502 PREFERRED Principal Principal Life Insurance Company Priority PriorityHealth PriorityHealth HMO Reliance Standard Life SAMBA Federal Health Plan Southland Benefit Solutions, LLC Superior Vision TransAmerica Financial Life Ins Company Tri-Care for Life (Medicare Supplement) Tricare North Region Health Net Federal Services, Inc.- c/o PGBA, LLC/TRICARE Tricare Prime TriWest UMR United Healthcare United Healthcare ST unknown Veterans Affair Vision Care Plus (VCP) VSP Webster West Inc Wellcare
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

Current Medical History:

Good health Arthritis Asthma Diabetes HBP Headaches Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Thyroid Disease Pregnant Now Nursing Diagnosed As HIV+ Other *

Diabetes HBP Heart disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other

Athritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems Other

Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other

Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Disease Back Problems Other

Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Other

Notes:

Pregnant Or Nursing:

No Yes Unsure Other

Pharmacy and Phone Number

OTC:

None Aspirin Acetominophen Ibuprofen Other

Vitamins:

None A E C Zinc Lutein Multivitamin Other

Family History:

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other *

Smoking Status

Current every day smoker Current some day smoker (not daily) Former smoker (no longer smokes) Heavy smoker (>10 cigs/day) Light smoker (<10 cigs/day) Never smoker (<100 cigs equiv) Smoker (current status unknown) Unknown if ever smoked Other *

Alcohol:

No Yes Occasionally Socially Other *

Race:*

Ethnicity: Not Hispanic or Latino or Spanish Origin Hispanic or Latino or Spanish Origin *

OCT

The Clarifye digital eye exam now includes retinal imaging using Optomap. This will not require dilation in most cases and will allow the doctor to assess the complete health of your eyes. It is standard of care for all patients at our practice as well as limits exposure during COVID. Without insurance, the exam fee is $119.00 and in most cases, when using insurance, it adds $39.00 to your exam copay.

In addition to the Optomap retinal imaging, we have state of the art technology which can give us a different aspect as well as more information for glaucoma, macular degeneration, diabetes, and other ocular pathology.

OCT Scan: OCT technology generates high-resolution, cross-sectional images of the retina and optic disc. This gives your Optometrist valuable information that aids in the diagnosis and management of a range of ocular diseases.

Please choose an option below. *

Yes, I would like the OCT Scan performed $14

No, I do not want the OCT Scan

* This test is for screening purposes and is not covered by insurance. *

Submit Data

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SIGNATURE FORMS

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Please sign below:

Signature:  *I have been given the opportunity to read this practice's HIPAA Privacy Policies.

Signature:  *I have read and understand the Patient Responsibility Disclosure Statement.

Signature:  *I have read and understand the Lenscrafter's Agreement.

** By entering my First and Last name, I understand, agree and accept that I am constituting a legally binding electronic signature, which I accept has the same validity and meaning as my handwritten signature.
________________________________________________________________________________________________________________________________________________
Please here. Thank You!

If you have any questions, please contact our offices:
Oxmoor 502-327-8568
Jefferson Mall 502-968-6860
Hamburg 859-543-0857