Demographics

Patient Information

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

Address:
City:		State/ZipCode	WA AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VI VT WI WV 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
Birth Sex	Male Female	Pronouns
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employment Status	Employed Full-Time Student Part-Time Student
Misc/Guardian		Employer / School Name

Is the Billing Address Different?

Billing Information

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

Copy Address From Above
Address

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

Home Phone:
Work Phone:

Vision Plan 1

Insurance Information

Metlife, Ameritas, Cigna Vision, and DeltaVision members please select "Vision Service Plan" as your Insurance Name.

Insurance Name:	None AARP (UNITED HEALTHCARE) AARP MEDICARE COMPLETE ADVENTIST RISK MANAGEMENT AETNA AETNA MEDICARE ALASKA LABORERS H & S FUND ALASKA MACHINISTS ALL SAVERS ALLEGIANCE BENEFIT PLAN MANAGEMENT ALWAYS CARE AMERICAN MERITIME OFFICERS ANTHEM REGENCE BLUESHIELD APWU HEALTH PLAN ASSOCIATION & SOCIETY INS. CORP. ASSOCIATION GROUP INS TRUST ASSURANT HEALTH ASURIS NORTHWEST HEALTH AW REHN & ASSOCIATES BANKERS FIDELITY LIFE BANKERS LIFE AND CASUALTY CO. BLUE CROSS BLUE SHIELD ILLINOIS BLUE CROSS BLUESHIELD NEBRASKA BLUE SHIELD CALIFORNIA BRIDGESPAN CARPENTERS HEALTH AND WELFARE CARPENTERS TRUST OF WESTERN WASHINGTON CEMENT MASONS AND PLASTERS CHAMPAVA/VA HEALTH ADMIN. CENTER CHP CLAIMS CIGNA CIGNA 1 CIGNA 2 CIGNA 3 CIGNA INTERNATIONAL CITY OF LYNNWOOD COLONIAL PENN LIFE INSURANCE CO. COMBINED INSURANCE CO OF AMERICA COMPASS ROSE HEALTH PLAN COVENTRY HEALTH CARE CYPRESS BENEFIT ADMINISTRATORS DELTA HEALTH SYSTEMS DEPARTMENT OF LABOR & INDUSTRIES DEPARTMENT OF LABOR & INDUSTRIES DEPT OF SOCIAL AND HEALTH SERVICES DESERT MUTUAL DR. HEDAHL EBMS EVERCARE EYE MED VISION FCHN FIRE FIGHTERS HEALTHCARE TRUST FIRST CHOICE HEALTH ADMINISTRATORS FOREIGN SERVICE BENEFIT PLAN GEHA Gilsbar GREAT WEST HEALTHCARE GROUP ADMINISTRATORS LTD GROUP HEALTH GUARDIAN GROUP HEALTH NET HEALTH NET FEDERAL HEALTHCOMP HEALTHSMART BENEFIT SOLUTIONS HIGHMARK BLUE SHIELD HMA HUMANA CLAIMS CENTER IBU NATIONAL HEALTH BENEFIT PLAN ILWU KAISER PERMANENTE KAISER PERMANENTE NORTHWEST REGION KAISER PERMANENTS NW KPS LEOFF HEALTH AND WELFARE TRUST LIBERTY LIFEWISE LINECO LOCAL 302 MAIL HANDLERS BENEFIT PLAN MASONRY SECURITY PLAN OF WASHINGTON MASTERS MATES AND PILOTS MEBA MEDICAL AND BENEFITS PLAN MEDICA MEDICAID MEDICARE PART B WASHINGTON MEDICARE SUPPLEMENT OPERATIONS MEDICO INSURANCE COMPANY MEDIPLUS THE HARTFORD MEGALIFE INSURANCE CENTER MERCER MERITAIN HEALTH MODA HEALTH MUTUAL OF OMAHA NEA GROUP INSURANCE PROGRAM NO CHART ! NORTHWEST ADMINISTRATORS NORTHWEST BENEFIT NETWORK NORTHWEST PLUMBING AND PIPEFITTING NORTHWEST SHEET METAL WORKERS NW IRON WORKERS NW LABORERS EMPLOYERS TRUST OLYMPIC HEALTH MANAGEMENT OXFORD HEALTH PLANS P5HEALTH DELTA HEALTH SYSTEMS PACIFIC CARE PACIFICSOURCE HEALTH PLANS PAINTERS TRUST PENSER NORTHAMERICA INC PLUMBING AND PIPEFITTING SEATTLE AREA POMCO GROUP PORT GAMBLE SKLALLAM TRIBE PREMERA BLUE CROSS PRINCIPAL LIFE INSURANCE CO PROVIDENCE HEALTH PLAN PSEW PUGET SOUND ELECTRICAL WORKERS HEALTH AND WELFARE TRUST RAILROAD MEDICARE PART B OFFICE REGENCE BLUESHIELD REGENCE FEDERAL EMPLOYEE PROGRAM REGENCE GROUP ADMINISTRATORS RETIREEE MEDICAL INSURANCE PLAN Rural Carrier Benefit Plan RWT FIRST CHOICE HEALTH NETWORK SAMBA SEABURY AND SMITH SEATTLE AREA PLUMBING AND PIPEFITTING SECURE HORIZONS SELECT BENEFIT ADMINISTRATION SHASTA ADMINISTRATIVE SERVICES SOUND HEALTH AND WELLNESS TRUST STANDARD LIFE AND ACCIDENT INSURANCE STATE FARM STATE FARM HEALTH INSURANCE STATE FARM INSURANCE STERLING OPTION 1 STONEBRIDGE LIFE SUQUAMISH TRIBE TEXAS MUTUAL THE EMPLOYEE PAINTERS TRUST THRIVENT FINANCIAL FOR LUTHERANS TONGASS TIMBER TRUST TPA TRANSAMERICA LIFE INS COMPANY TRIBAL FIRST TRICARE TRISTAR BENEFIT ADMINISTRATORS TRUSTEED PLANS SERVICE CORPORATION UMR UMR-0704 UNICARE UNITED UNITED 2 UNITED 3 UNITED 4 UNITED 5 UNITED 7 UNITED 8 UNITED AMERICAN INSURANCE CO. UNITED HEALTHCHARE UNITED WORLD LIFE INS. CO. UNIVERA HEALTHCARE US FAMILY HEALTH PLAN US FAMILY HEALTH PLAN AT PACMED USAA LIFE INSURANCE COMPANY VA VISION SERVICE PLAN WA TEAMSTER WELFARE TRUST WASHINGTON BAKERS TRUST WASHINGTON STATE HEALTH INSURANCE POOL WASHINGTONS EMPLOYERS TRUST WEBTPA WELFARE & PENSION ADMIN WELLS FARGO INSURANCE SERVICES WESTERN GROCERS BENEFITS TRUST Western United LIfe WOODWARD HEALTH CARE SVC CENTER WORLDINS WPAS WPAS UW CLAIMS OFFICE WPS-VAPCC ZENITH ADMINISTRATORS INC
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 2

Insurance Information

Metlife, Ameritas, Cigna Vision, and DeltaVision members please select "Vision Service Plan" as your Insurance Name.

Insurance Name:	None AARP (UNITED HEALTHCARE) AARP MEDICARE COMPLETE ADVENTIST RISK MANAGEMENT AETNA AETNA MEDICARE ALASKA LABORERS H & S FUND ALASKA MACHINISTS ALL SAVERS ALLEGIANCE BENEFIT PLAN MANAGEMENT ALWAYS CARE AMERICAN MERITIME OFFICERS ANTHEM REGENCE BLUESHIELD APWU HEALTH PLAN ASSOCIATION & SOCIETY INS. CORP. ASSOCIATION GROUP INS TRUST ASSURANT HEALTH ASURIS NORTHWEST HEALTH AW REHN & ASSOCIATES BANKERS FIDELITY LIFE BANKERS LIFE AND CASUALTY CO. BLUE CROSS BLUE SHIELD ILLINOIS BLUE CROSS BLUESHIELD NEBRASKA BLUE SHIELD CALIFORNIA BRIDGESPAN CARPENTERS HEALTH AND WELFARE CARPENTERS TRUST OF WESTERN WASHINGTON CEMENT MASONS AND PLASTERS CHAMPAVA/VA HEALTH ADMIN. CENTER CHP CLAIMS CIGNA CIGNA 1 CIGNA 2 CIGNA 3 CIGNA INTERNATIONAL CITY OF LYNNWOOD COLONIAL PENN LIFE INSURANCE CO. COMBINED INSURANCE CO OF AMERICA COMPASS ROSE HEALTH PLAN COVENTRY HEALTH CARE CYPRESS BENEFIT ADMINISTRATORS DELTA HEALTH SYSTEMS DEPARTMENT OF LABOR & INDUSTRIES DEPARTMENT OF LABOR & INDUSTRIES DEPT OF SOCIAL AND HEALTH SERVICES DESERT MUTUAL DR. HEDAHL EBMS EVERCARE EYE MED VISION FCHN FIRE FIGHTERS HEALTHCARE TRUST FIRST CHOICE HEALTH ADMINISTRATORS FOREIGN SERVICE BENEFIT PLAN GEHA Gilsbar GREAT WEST HEALTHCARE GROUP ADMINISTRATORS LTD GROUP HEALTH GUARDIAN GROUP HEALTH NET HEALTH NET FEDERAL HEALTHCOMP HEALTHSMART BENEFIT SOLUTIONS HIGHMARK BLUE SHIELD HMA HUMANA CLAIMS CENTER IBU NATIONAL HEALTH BENEFIT PLAN ILWU KAISER PERMANENTE KAISER PERMANENTE NORTHWEST REGION KAISER PERMANENTS NW KPS LEOFF HEALTH AND WELFARE TRUST LIBERTY LIFEWISE LINECO LOCAL 302 MAIL HANDLERS BENEFIT PLAN MASONRY SECURITY PLAN OF WASHINGTON MASTERS MATES AND PILOTS MEBA MEDICAL AND BENEFITS PLAN MEDICA MEDICAID MEDICARE PART B WASHINGTON MEDICARE SUPPLEMENT OPERATIONS MEDICO INSURANCE COMPANY MEDIPLUS THE HARTFORD MEGALIFE INSURANCE CENTER MERCER MERITAIN HEALTH MODA HEALTH MUTUAL OF OMAHA NEA GROUP INSURANCE PROGRAM NO CHART ! NORTHWEST ADMINISTRATORS NORTHWEST BENEFIT NETWORK NORTHWEST PLUMBING AND PIPEFITTING NORTHWEST SHEET METAL WORKERS NW IRON WORKERS NW LABORERS EMPLOYERS TRUST OLYMPIC HEALTH MANAGEMENT OXFORD HEALTH PLANS P5HEALTH DELTA HEALTH SYSTEMS PACIFIC CARE PACIFICSOURCE HEALTH PLANS PAINTERS TRUST PENSER NORTHAMERICA INC PLUMBING AND PIPEFITTING SEATTLE AREA POMCO GROUP PORT GAMBLE SKLALLAM TRIBE PREMERA BLUE CROSS PRINCIPAL LIFE INSURANCE CO PROVIDENCE HEALTH PLAN PSEW PUGET SOUND ELECTRICAL WORKERS HEALTH AND WELFARE TRUST RAILROAD MEDICARE PART B OFFICE REGENCE BLUESHIELD REGENCE FEDERAL EMPLOYEE PROGRAM REGENCE GROUP ADMINISTRATORS RETIREEE MEDICAL INSURANCE PLAN Rural Carrier Benefit Plan RWT FIRST CHOICE HEALTH NETWORK SAMBA SEABURY AND SMITH SEATTLE AREA PLUMBING AND PIPEFITTING SECURE HORIZONS SELECT BENEFIT ADMINISTRATION SHASTA ADMINISTRATIVE SERVICES SOUND HEALTH AND WELLNESS TRUST STANDARD LIFE AND ACCIDENT INSURANCE STATE FARM STATE FARM HEALTH INSURANCE STATE FARM INSURANCE STERLING OPTION 1 STONEBRIDGE LIFE SUQUAMISH TRIBE TEXAS MUTUAL THE EMPLOYEE PAINTERS TRUST THRIVENT FINANCIAL FOR LUTHERANS TONGASS TIMBER TRUST TPA TRANSAMERICA LIFE INS COMPANY TRIBAL FIRST TRICARE TRISTAR BENEFIT ADMINISTRATORS TRUSTEED PLANS SERVICE CORPORATION UMR UMR-0704 UNICARE UNITED UNITED 2 UNITED 3 UNITED 4 UNITED 5 UNITED 7 UNITED 8 UNITED AMERICAN INSURANCE CO. UNITED HEALTHCHARE UNITED WORLD LIFE INS. CO. UNIVERA HEALTHCARE US FAMILY HEALTH PLAN US FAMILY HEALTH PLAN AT PACMED USAA LIFE INSURANCE COMPANY VA VISION SERVICE PLAN WA TEAMSTER WELFARE TRUST WASHINGTON BAKERS TRUST WASHINGTON STATE HEALTH INSURANCE POOL WASHINGTONS EMPLOYERS TRUST WEBTPA WELFARE & PENSION ADMIN WELLS FARGO INSURANCE SERVICES WESTERN GROCERS BENEFITS TRUST Western United LIfe WOODWARD HEALTH CARE SVC CENTER WORLDINS WPAS WPAS UW CLAIMS OFFICE WPS-VAPCC ZENITH ADMINISTRATORS INC
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:

Primary

Insurance Information

Insurance Name:	None AARP (UNITED HEALTHCARE) AARP MEDICARE COMPLETE ADVENTIST RISK MANAGEMENT AETNA AETNA MEDICARE ALASKA LABORERS H & S FUND ALASKA MACHINISTS ALL SAVERS ALLEGIANCE BENEFIT PLAN MANAGEMENT ALWAYS CARE AMERICAN MERITIME OFFICERS ANTHEM REGENCE BLUESHIELD APWU HEALTH PLAN ASSOCIATION & SOCIETY INS. CORP. ASSOCIATION GROUP INS TRUST ASSURANT HEALTH ASURIS NORTHWEST HEALTH AW REHN & ASSOCIATES BANKERS FIDELITY LIFE BANKERS LIFE AND CASUALTY CO. BLUE CROSS BLUE SHIELD ILLINOIS BLUE CROSS BLUESHIELD NEBRASKA BLUE SHIELD CALIFORNIA BRIDGESPAN CARPENTERS HEALTH AND WELFARE CARPENTERS TRUST OF WESTERN WASHINGTON CEMENT MASONS AND PLASTERS CHAMPAVA/VA HEALTH ADMIN. CENTER CHP CLAIMS CIGNA CIGNA 1 CIGNA 2 CIGNA 3 CIGNA INTERNATIONAL CITY OF LYNNWOOD COLONIAL PENN LIFE INSURANCE CO. COMBINED INSURANCE CO OF AMERICA COMPASS ROSE HEALTH PLAN COVENTRY HEALTH CARE CYPRESS BENEFIT ADMINISTRATORS DELTA HEALTH SYSTEMS DEPARTMENT OF LABOR & INDUSTRIES DEPARTMENT OF LABOR & INDUSTRIES DEPT OF SOCIAL AND HEALTH SERVICES DESERT MUTUAL DR. HEDAHL EBMS EVERCARE EYE MED VISION FCHN FIRE FIGHTERS HEALTHCARE TRUST FIRST CHOICE HEALTH ADMINISTRATORS FOREIGN SERVICE BENEFIT PLAN GEHA Gilsbar GREAT WEST HEALTHCARE GROUP ADMINISTRATORS LTD GROUP HEALTH GUARDIAN GROUP HEALTH NET HEALTH NET FEDERAL HEALTHCOMP HEALTHSMART BENEFIT SOLUTIONS HIGHMARK BLUE SHIELD HMA HUMANA CLAIMS CENTER IBU NATIONAL HEALTH BENEFIT PLAN ILWU KAISER PERMANENTE KAISER PERMANENTE NORTHWEST REGION KAISER PERMANENTS NW KPS LEOFF HEALTH AND WELFARE TRUST LIBERTY LIFEWISE LINECO LOCAL 302 MAIL HANDLERS BENEFIT PLAN MASONRY SECURITY PLAN OF WASHINGTON MASTERS MATES AND PILOTS MEBA MEDICAL AND BENEFITS PLAN MEDICA MEDICAID MEDICARE PART B WASHINGTON MEDICARE SUPPLEMENT OPERATIONS MEDICO INSURANCE COMPANY MEDIPLUS THE HARTFORD MEGALIFE INSURANCE CENTER MERCER MERITAIN HEALTH MODA HEALTH MUTUAL OF OMAHA NEA GROUP INSURANCE PROGRAM NO CHART ! NORTHWEST ADMINISTRATORS NORTHWEST BENEFIT NETWORK NORTHWEST PLUMBING AND PIPEFITTING NORTHWEST SHEET METAL WORKERS NW IRON WORKERS NW LABORERS EMPLOYERS TRUST OLYMPIC HEALTH MANAGEMENT OXFORD HEALTH PLANS P5HEALTH DELTA HEALTH SYSTEMS PACIFIC CARE PACIFICSOURCE HEALTH PLANS PAINTERS TRUST PENSER NORTHAMERICA INC PLUMBING AND PIPEFITTING SEATTLE AREA POMCO GROUP PORT GAMBLE SKLALLAM TRIBE PREMERA BLUE CROSS PRINCIPAL LIFE INSURANCE CO PROVIDENCE HEALTH PLAN PSEW PUGET SOUND ELECTRICAL WORKERS HEALTH AND WELFARE TRUST RAILROAD MEDICARE PART B OFFICE REGENCE BLUESHIELD REGENCE FEDERAL EMPLOYEE PROGRAM REGENCE GROUP ADMINISTRATORS RETIREEE MEDICAL INSURANCE PLAN Rural Carrier Benefit Plan RWT FIRST CHOICE HEALTH NETWORK SAMBA SEABURY AND SMITH SEATTLE AREA PLUMBING AND PIPEFITTING SECURE HORIZONS SELECT BENEFIT ADMINISTRATION SHASTA ADMINISTRATIVE SERVICES SOUND HEALTH AND WELLNESS TRUST STANDARD LIFE AND ACCIDENT INSURANCE STATE FARM STATE FARM HEALTH INSURANCE STATE FARM INSURANCE STERLING OPTION 1 STONEBRIDGE LIFE SUQUAMISH TRIBE TEXAS MUTUAL THE EMPLOYEE PAINTERS TRUST THRIVENT FINANCIAL FOR LUTHERANS TONGASS TIMBER TRUST TPA TRANSAMERICA LIFE INS COMPANY TRIBAL FIRST TRICARE TRISTAR BENEFIT ADMINISTRATORS TRUSTEED PLANS SERVICE CORPORATION UMR UMR-0704 UNICARE UNITED UNITED 2 UNITED 3 UNITED 4 UNITED 5 UNITED 7 UNITED 8 UNITED AMERICAN INSURANCE CO. UNITED HEALTHCHARE UNITED WORLD LIFE INS. CO. UNIVERA HEALTHCARE US FAMILY HEALTH PLAN US FAMILY HEALTH PLAN AT PACMED USAA LIFE INSURANCE COMPANY VA VISION SERVICE PLAN WA TEAMSTER WELFARE TRUST WASHINGTON BAKERS TRUST WASHINGTON STATE HEALTH INSURANCE POOL WASHINGTONS EMPLOYERS TRUST WEBTPA WELFARE & PENSION ADMIN WELLS FARGO INSURANCE SERVICES WESTERN GROCERS BENEFITS TRUST Western United LIfe WOODWARD HEALTH CARE SVC CENTER WORLDINS WPAS WPAS UW CLAIMS OFFICE WPS-VAPCC ZENITH ADMINISTRATORS INC
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:

Secondary

Insurance Information

Insurance Name:	None AARP (UNITED HEALTHCARE) AARP MEDICARE COMPLETE ADVENTIST RISK MANAGEMENT AETNA AETNA MEDICARE ALASKA LABORERS H & S FUND ALASKA MACHINISTS ALL SAVERS ALLEGIANCE BENEFIT PLAN MANAGEMENT ALWAYS CARE AMERICAN MERITIME OFFICERS ANTHEM REGENCE BLUESHIELD APWU HEALTH PLAN ASSOCIATION & SOCIETY INS. CORP. ASSOCIATION GROUP INS TRUST ASSURANT HEALTH ASURIS NORTHWEST HEALTH AW REHN & ASSOCIATES BANKERS FIDELITY LIFE BANKERS LIFE AND CASUALTY CO. BLUE CROSS BLUE SHIELD ILLINOIS BLUE CROSS BLUESHIELD NEBRASKA BLUE SHIELD CALIFORNIA BRIDGESPAN CARPENTERS HEALTH AND WELFARE CARPENTERS TRUST OF WESTERN WASHINGTON CEMENT MASONS AND PLASTERS CHAMPAVA/VA HEALTH ADMIN. CENTER CHP CLAIMS CIGNA CIGNA 1 CIGNA 2 CIGNA 3 CIGNA INTERNATIONAL CITY OF LYNNWOOD COLONIAL PENN LIFE INSURANCE CO. COMBINED INSURANCE CO OF AMERICA COMPASS ROSE HEALTH PLAN COVENTRY HEALTH CARE CYPRESS BENEFIT ADMINISTRATORS DELTA HEALTH SYSTEMS DEPARTMENT OF LABOR & INDUSTRIES DEPARTMENT OF LABOR & INDUSTRIES DEPT OF SOCIAL AND HEALTH SERVICES DESERT MUTUAL DR. HEDAHL EBMS EVERCARE EYE MED VISION FCHN FIRE FIGHTERS HEALTHCARE TRUST FIRST CHOICE HEALTH ADMINISTRATORS FOREIGN SERVICE BENEFIT PLAN GEHA Gilsbar GREAT WEST HEALTHCARE GROUP ADMINISTRATORS LTD GROUP HEALTH GUARDIAN GROUP HEALTH NET HEALTH NET FEDERAL HEALTHCOMP HEALTHSMART BENEFIT SOLUTIONS HIGHMARK BLUE SHIELD HMA HUMANA CLAIMS CENTER IBU NATIONAL HEALTH BENEFIT PLAN ILWU KAISER PERMANENTE KAISER PERMANENTE NORTHWEST REGION KAISER PERMANENTS NW KPS LEOFF HEALTH AND WELFARE TRUST LIBERTY LIFEWISE LINECO LOCAL 302 MAIL HANDLERS BENEFIT PLAN MASONRY SECURITY PLAN OF WASHINGTON MASTERS MATES AND PILOTS MEBA MEDICAL AND BENEFITS PLAN MEDICA MEDICAID MEDICARE PART B WASHINGTON MEDICARE SUPPLEMENT OPERATIONS MEDICO INSURANCE COMPANY MEDIPLUS THE HARTFORD MEGALIFE INSURANCE CENTER MERCER MERITAIN HEALTH MODA HEALTH MUTUAL OF OMAHA NEA GROUP INSURANCE PROGRAM NO CHART ! NORTHWEST ADMINISTRATORS NORTHWEST BENEFIT NETWORK NORTHWEST PLUMBING AND PIPEFITTING NORTHWEST SHEET METAL WORKERS NW IRON WORKERS NW LABORERS EMPLOYERS TRUST OLYMPIC HEALTH MANAGEMENT OXFORD HEALTH PLANS P5HEALTH DELTA HEALTH SYSTEMS PACIFIC CARE PACIFICSOURCE HEALTH PLANS PAINTERS TRUST PENSER NORTHAMERICA INC PLUMBING AND PIPEFITTING SEATTLE AREA POMCO GROUP PORT GAMBLE SKLALLAM TRIBE PREMERA BLUE CROSS PRINCIPAL LIFE INSURANCE CO PROVIDENCE HEALTH PLAN PSEW PUGET SOUND ELECTRICAL WORKERS HEALTH AND WELFARE TRUST RAILROAD MEDICARE PART B OFFICE REGENCE BLUESHIELD REGENCE FEDERAL EMPLOYEE PROGRAM REGENCE GROUP ADMINISTRATORS RETIREEE MEDICAL INSURANCE PLAN Rural Carrier Benefit Plan RWT FIRST CHOICE HEALTH NETWORK SAMBA SEABURY AND SMITH SEATTLE AREA PLUMBING AND PIPEFITTING SECURE HORIZONS SELECT BENEFIT ADMINISTRATION SHASTA ADMINISTRATIVE SERVICES SOUND HEALTH AND WELLNESS TRUST STANDARD LIFE AND ACCIDENT INSURANCE STATE FARM STATE FARM HEALTH INSURANCE STATE FARM INSURANCE STERLING OPTION 1 STONEBRIDGE LIFE SUQUAMISH TRIBE TEXAS MUTUAL THE EMPLOYEE PAINTERS TRUST THRIVENT FINANCIAL FOR LUTHERANS TONGASS TIMBER TRUST TPA TRANSAMERICA LIFE INS COMPANY TRIBAL FIRST TRICARE TRISTAR BENEFIT ADMINISTRATORS TRUSTEED PLANS SERVICE CORPORATION UMR UMR-0704 UNICARE UNITED UNITED 2 UNITED 3 UNITED 4 UNITED 5 UNITED 7 UNITED 8 UNITED AMERICAN INSURANCE CO. UNITED HEALTHCHARE UNITED WORLD LIFE INS. CO. UNIVERA HEALTHCARE US FAMILY HEALTH PLAN US FAMILY HEALTH PLAN AT PACMED USAA LIFE INSURANCE COMPANY VA VISION SERVICE PLAN WA TEAMSTER WELFARE TRUST WASHINGTON BAKERS TRUST WASHINGTON STATE HEALTH INSURANCE POOL WASHINGTONS EMPLOYERS TRUST WEBTPA WELFARE & PENSION ADMIN WELLS FARGO INSURANCE SERVICES WESTERN GROCERS BENEFITS TRUST Western United LIfe WOODWARD HEALTH CARE SVC CENTER WORLDINS WPAS WPAS UW CLAIMS OFFICE WPS-VAPCC ZENITH ADMINISTRATORS INC
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:

Tertiary

Insurance Information

Insurance Name:	None AARP (UNITED HEALTHCARE) AARP MEDICARE COMPLETE ADVENTIST RISK MANAGEMENT AETNA AETNA MEDICARE ALASKA LABORERS H & S FUND ALASKA MACHINISTS ALL SAVERS ALLEGIANCE BENEFIT PLAN MANAGEMENT ALWAYS CARE AMERICAN MERITIME OFFICERS ANTHEM REGENCE BLUESHIELD APWU HEALTH PLAN ASSOCIATION & SOCIETY INS. CORP. ASSOCIATION GROUP INS TRUST ASSURANT HEALTH ASURIS NORTHWEST HEALTH AW REHN & ASSOCIATES BANKERS FIDELITY LIFE BANKERS LIFE AND CASUALTY CO. BLUE CROSS BLUE SHIELD ILLINOIS BLUE CROSS BLUESHIELD NEBRASKA BLUE SHIELD CALIFORNIA BRIDGESPAN CARPENTERS HEALTH AND WELFARE CARPENTERS TRUST OF WESTERN WASHINGTON CEMENT MASONS AND PLASTERS CHAMPAVA/VA HEALTH ADMIN. CENTER CHP CLAIMS CIGNA CIGNA 1 CIGNA 2 CIGNA 3 CIGNA INTERNATIONAL CITY OF LYNNWOOD COLONIAL PENN LIFE INSURANCE CO. COMBINED INSURANCE CO OF AMERICA COMPASS ROSE HEALTH PLAN COVENTRY HEALTH CARE CYPRESS BENEFIT ADMINISTRATORS DELTA HEALTH SYSTEMS DEPARTMENT OF LABOR & INDUSTRIES DEPARTMENT OF LABOR & INDUSTRIES DEPT OF SOCIAL AND HEALTH SERVICES DESERT MUTUAL DR. HEDAHL EBMS EVERCARE EYE MED VISION FCHN FIRE FIGHTERS HEALTHCARE TRUST FIRST CHOICE HEALTH ADMINISTRATORS FOREIGN SERVICE BENEFIT PLAN GEHA Gilsbar GREAT WEST HEALTHCARE GROUP ADMINISTRATORS LTD GROUP HEALTH GUARDIAN GROUP HEALTH NET HEALTH NET FEDERAL HEALTHCOMP HEALTHSMART BENEFIT SOLUTIONS HIGHMARK BLUE SHIELD HMA HUMANA CLAIMS CENTER IBU NATIONAL HEALTH BENEFIT PLAN ILWU KAISER PERMANENTE KAISER PERMANENTE NORTHWEST REGION KAISER PERMANENTS NW KPS LEOFF HEALTH AND WELFARE TRUST LIBERTY LIFEWISE LINECO LOCAL 302 MAIL HANDLERS BENEFIT PLAN MASONRY SECURITY PLAN OF WASHINGTON MASTERS MATES AND PILOTS MEBA MEDICAL AND BENEFITS PLAN MEDICA MEDICAID MEDICARE PART B WASHINGTON MEDICARE SUPPLEMENT OPERATIONS MEDICO INSURANCE COMPANY MEDIPLUS THE HARTFORD MEGALIFE INSURANCE CENTER MERCER MERITAIN HEALTH MODA HEALTH MUTUAL OF OMAHA NEA GROUP INSURANCE PROGRAM NO CHART ! NORTHWEST ADMINISTRATORS NORTHWEST BENEFIT NETWORK NORTHWEST PLUMBING AND PIPEFITTING NORTHWEST SHEET METAL WORKERS NW IRON WORKERS NW LABORERS EMPLOYERS TRUST OLYMPIC HEALTH MANAGEMENT OXFORD HEALTH PLANS P5HEALTH DELTA HEALTH SYSTEMS PACIFIC CARE PACIFICSOURCE HEALTH PLANS PAINTERS TRUST PENSER NORTHAMERICA INC PLUMBING AND PIPEFITTING SEATTLE AREA POMCO GROUP PORT GAMBLE SKLALLAM TRIBE PREMERA BLUE CROSS PRINCIPAL LIFE INSURANCE CO PROVIDENCE HEALTH PLAN PSEW PUGET SOUND ELECTRICAL WORKERS HEALTH AND WELFARE TRUST RAILROAD MEDICARE PART B OFFICE REGENCE BLUESHIELD REGENCE FEDERAL EMPLOYEE PROGRAM REGENCE GROUP ADMINISTRATORS RETIREEE MEDICAL INSURANCE PLAN Rural Carrier Benefit Plan RWT FIRST CHOICE HEALTH NETWORK SAMBA SEABURY AND SMITH SEATTLE AREA PLUMBING AND PIPEFITTING SECURE HORIZONS SELECT BENEFIT ADMINISTRATION SHASTA ADMINISTRATIVE SERVICES SOUND HEALTH AND WELLNESS TRUST STANDARD LIFE AND ACCIDENT INSURANCE STATE FARM STATE FARM HEALTH INSURANCE STATE FARM INSURANCE STERLING OPTION 1 STONEBRIDGE LIFE SUQUAMISH TRIBE TEXAS MUTUAL THE EMPLOYEE PAINTERS TRUST THRIVENT FINANCIAL FOR LUTHERANS TONGASS TIMBER TRUST TPA TRANSAMERICA LIFE INS COMPANY TRIBAL FIRST TRICARE TRISTAR BENEFIT ADMINISTRATORS TRUSTEED PLANS SERVICE CORPORATION UMR UMR-0704 UNICARE UNITED UNITED 2 UNITED 3 UNITED 4 UNITED 5 UNITED 7 UNITED 8 UNITED AMERICAN INSURANCE CO. UNITED HEALTHCHARE UNITED WORLD LIFE INS. CO. UNIVERA HEALTHCARE US FAMILY HEALTH PLAN US FAMILY HEALTH PLAN AT PACMED USAA LIFE INSURANCE COMPANY VA VISION SERVICE PLAN WA TEAMSTER WELFARE TRUST WASHINGTON BAKERS TRUST WASHINGTON STATE HEALTH INSURANCE POOL WASHINGTONS EMPLOYERS TRUST WEBTPA WELFARE & PENSION ADMIN WELLS FARGO INSURANCE SERVICES WESTERN GROCERS BENEFITS TRUST Western United LIfe WOODWARD HEALTH CARE SVC CENTER WORLDINS WPAS WPAS UW CLAIMS OFFICE WPS-VAPCC ZENITH ADMINISTRATORS INC
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

Eye / Medical History

What Is The Primary Reason For Visit?

Last Eye Exam:

1 year 2 years 3 years 4 years 5 years > 5 years First Other

Doctor:

Glasses?

Yes No All the timeDrivingOccasionallyWatching televisionReadingComputer

Contacts?

Yes No

Symptoms Checklist

Eye Medications

EYES

Dryness

Itching

Burning

Watery/Tearing

Discharge/Crusting

Redness

Pain

Strain/Pulling

Eyelid droop

Sandy/Gritty Feeling

Eyelid twitching

VISION

Double vision

Blurred Vision-Distance

Poor night vision

Light Sensitive

Floaters

Flashing lights

Blurred Vision-Near

Glare/Halos

Current And Past Eye History / Surgical Checklist

Cataracts

No Yes Previously Other      Cataract Surgery

Glaucoma

No Yes Previously Other      Glaucoma Surgery

Macular Degeneration

No Yes Previously Other      Injections for Macular Degeneration

Retinal Disease or Detachments

No Yes Previously Other      Retinal Surgery

Corneal Disease

No Yes Previously Other      Corneal Surgery (RK, PRK, LASIK)

Eye Infections

No Yes Previously Other

Eye Injury/Trauma

No Yes Previously Other

Temporary Vision Loss

No Yes Previously Other

Crossed/Lazy Eye

No Yes Previously Other      Strabismus/Eye Muscle Surgery

Family Ocular History

Macular Degen:

No Parents Siblings Grandparent Other

Glaucoma:

No Sibling Aunt Uncle Parent Grand Parent Great Grand Parent Other

Cataracts:

No Parents Siblings Grandparent Other

Retinal Detach:

No Parents Siblings Grandparent Other

Crossed / Lazy:

No Parents Siblings Grandparent Other

Corneal Disease

No Yes Other

Other:

Personal Medical History / Family Medical History / Social History

Answer: Yes or No or Previously

Allergies

No Yes Previous Other

High Blood Pressure

No Yes Previous Other

Heart Disease

No Yes Previous Other

Asthma/Lung Disease

No Yes Previous Other

Kidney Disease

No Yes Other

Arthritis/Autoimmune Disease

No Yes Previous Other

Migraine Headaches

No Yes Previous Other

Thyroid Disease

No Yes Previous Other

Diabetes

No Yes Previous Other

A1C Level

High Cholesterol

No Yes Previous Other

Anxiety or Depression

No Yes Previous Other

Heart Attack

No Yes Previous Other

Cancer

No Breast Prostate Basal Cell Uterine Lung Other

AIDS/HIV

No Yes Other

Stroke

No Yes Other

Shingles

No Yes Other

Pregnant Or Nursing:

No Yes Unsure Other

Premature Birth

No Yes Other

Current and Past Medical History

No Current Medications
No Known Drug Allergies

Primary Care Physician

Last Med. Exam:

1 year 1 week 1 month 3 months 6 months 2 years Never Unsure Other

Systemic Meds:

None

Drug Allergies

No Known Drug Allergies

Injuries, Surgeries, Hospitalization

NO

Family Medical History

FAMILY MEDICAL HISTORY - Unknown family history

None

Social History

Tobacco (Age 13+)

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

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 Other

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