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	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Ansari MD, Irfan Dr. Harlan, OD, Aubrey	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 1st Sargeant Hedden 3M Safety Glasses AAG AARP Acordia National Administrative Concepts Inc Advantra Freedom Advantra GHP Aetna Aetna 1125 Aetna 14079 Aetna 14089 Aetna 14094 Aetna 14100 Aetna 14586 Aetna 30258 Aetna 795080 Aetna 981106 Aetna 981109 Aetna 981204 Aetna Medicare 981107 Aetna Medicare Pffs Aetna Us Healthcare AFLAC Aftra Health Fund AIG Accident & Health Clms Alicare Inc Local 161 Allied Benefit Systems Allied National/co Global Care Inc AMA Insurance American Adm Group Inc American Adm Group Inc American Continatial American Family Insurance American Heritage Life Insurance Company American Medical Security American Pioneer Life American Postal Workers Union American Progressive Claims American Republic Insurance Amerihealth Adm APAIE LOCAL 618 APWU APWU Health Plan ASRM Association & Society Ins Corp Assurant Health Aultcare Auto Insurance Auto Owners Insurance Avesis Avesis Medicaid AVMA Group Health Ball State University Baltas Vision Bankers Fidelity Bankers Life And Casualty Bankers Life And Casualty Co Bankers Life And Casualty Co BAS LLC Beech Street Corp Beechstreet Benefit Consultants Inc Benefit Management Services Inc Benefit Plan Adm Of Wisc Benefit Plan Management Benefit Planners Benefits Management Inc BeneScript BENESIGHT Best Life Block Vision Blue Choice Blue Cross and Blue Shield of Kentucky Blue Cross Blue Shield - Empire Blue Cross Blue Shield Of Illinois Blue Vision Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Wells Fargo TPA Bluegrass Network Bradford Square Bridgestone Americas, Inc. C L Frates And Company California Secure Horizons Capella Group Care Improvement Plus Care Management Resource CMR Care Management Resources Carpenters Health Welfare CBA CBS PERSONNEL CBSA Central Reserve Central States H&W Fund Central States Indemnity Central United Life Cerner Health CHA Champva Center Dept Of Treasury CHBA Chesterfield Resources Inc Chickering Claims Chickering Claims Adm Christian Brothers HMSR Christian Care Medi Share Christian Fidelity 44990 Christian Fidelity 5840 Cigna Cigna 15050 Cigna 182223 Cigna 3020 Cigna 3058 Cigna 5200 Cigna 55270 Cigna 62308 Cigna 997561 Cigna Healthcare 32894 Cigna Healthcare 5909 Cigna HMO CMI Colonial Penn Life Ins Combined Insurance Combined Insurance Co Commerce Benefits Group Clms Connecticut General Insurance Company Conseco Health Constitution Life Ins Continental American Ins Co Continental General Life Continental Life Cooperate Benifit Administrators Coresource 2920 Coresource 5200 Country Life Insurance Company Coventry Health Care 8400 Coventry Health Care 8401 Coventry Healthcare Of Kansas City CoventryCares Medicaid Davis Vision Deal Makers Auto Sales Of Frankfort Definity Health Plan Phcs Deseret Mutual Directpay Disability Management Diversified Adm Corporation EBA Employee Benefits Administrators Emerson Appliance Solutions Employment Plus Epoch Equitable Life Essence Medicare HMO Evercare Exclusive Choice EyeMed Farm Bureau Federated Claims Services First Health 24220 First Health 6249 First Health 8400 First Health 8401 First Health Direct First Health Network Fiserv Health 725 Fiserv Health 8031 Fiserv Health 8077 Fiserve Health-Kansas FMH Fore Thought Fortis Ins FRMC ER Coverage GE Health Manager GE Life And Annuity GEHA Genesis Health Plans GHP 7112 GHP 7121 GHP 7374 Global Excel Management Globe Life Gold Advantage Golden Living Golden Rule Insurance Grange Insurance Great West Life Assurance Company Group & Pension Adm Inc Guarantee Trust Guardian Harrington Benefits Hartford Ins Co/mediplus Hartford Life And Accident Haskell Health Center Health Alliance Medical Plans Health Benefit Plan Health Choices Health Plan Services Healthcare USA Healthfirst TPA Healthlink HMO Healthlink Open Access Healthlink PPO HealthPartners Claim Healthplus PPO Healthscope Benefits HealthSmart Preferred Care HealthStar HFN Inc HMSA BCBS HNA/FSC/CHCA HSI Health Strategic Init HSR Administrators Humana Humana Gold Choice Humana One Humana VCP IAC Illinois Medicaid Indiana State Council Of Roofers Insurers Adm Corp IUOE Local 513 James B. Haggin Memorial Hospital Johnston Companies/USA H&W Network JSL Administrators Inc K&K Insurance Kaiser Permanente Kentucky Access Kentucky Access Kentucky Disability Kentucky Spirit Medicaid KVP KY Office For Blind Liberty Mutual Ins Lincoln Heritage Life Ins Local 176 Health & Welfare Loomis Company SKF USA Lumenos Mail Handlers Benefit Mail Handlers Benefit Plan McGregor & Associates Med Link Healthcare Networks Inc Medben Medi-share Processing Center Medicaid Medical Mutual Medicare Complete Choice Medicare Complete/Secure Horizons Medicare DME Medicare Illinois Medicare Part B Cigna Government Service Medicare Railroad Medico Mega Life Mega Life And Health Insurance Company Mega Life Star Hrg Mercer Administration Mercy Careplus Mercy Health Plans Mercy Premier Plus Meritain Health Metlife Midwest Security Adm Inc Missouri Employers Mutual/MEMIC Monoplast Of North America Monoplast Of North America Monumental Life Insurance Company Mutual Of Omaha Mutual Of Omaha Mutual Of Omaha Co Mutual Of Omaha/Charlotte Center Mutual Protective MVP NALC NASI National Foundation Life Ins Co National States National Vision Administrators Nationwide Health Plans NEIHBP New Era Life Ins North American Administrators ODS Office For The Blind One Heath Plan Operating Engineers Local 513 Opticare OptiCare Medicaid Oxford Health Oxford Health Plans P5 Health Plans Solutions Pacific Source Health Plans Pacificare Pacificare Of Arizona Painters District 2 Welfare Passport Advantage Passport Health Plan Pekin Life Ins Pennsylvania Life Insurance Performax 27725 Performax 61505 PersonalCare Philadelphia American Life Phillips Administrative Service Inc Physicians Mutual Plan Administrative Incorporated PAI Plumbers & Pipefitters Local 562 PPOM Preferred Care Preferred Health Plan Preferred One Administrative Services Priests Mutual Benefit Primary PhysicianCare Inc Principal Financial Principal Life Insurance Company Principal Mutual Life Private Healthcare Systems 12170 Private Healthcare Systems 13845 Progressive Benefits Service Pyramid Claims Pyramid Life Quality Benefits Llc/claims Processing Reliance Standard Religious Comprehensive Trust Reserve National Insurance Retiree Medical Insurance Plan RMSCO Inc. Royal Neighbors Of America RR Medicare Safe Auto SAMBA Seabury And Smith ELCA Seven Corners Sheet Metal Local 36 Sheet Metal Workers/SMW+ Shelter Insurance Shenandoah Life Ins Co Sierra Health And Life Sisco Smith Administrators SOI Health Plan/First Health Network Southern Il Health Spectera Vision SS Healthcare Strategies St John's Claim Adm St Louis Graphic Arts Standard Life And Accident 1800 Standard Life And Accident 25097 Star HRG Starmark State Farm Health Ins 339403 State Farm Health Ins 9403 State Farm Ins State Mutual Insurance Sterling Life Ins Co Strategic Resource Co Superior Vision TCS Teamcare Teamsters Medicare Trust Local 688 The Benefit Group The Corps Network Thrivent Financial For Lutherans Time Insurance Tower Life Ins Co Travelers Construction Workers Comp Travelers Insurance Tricare North Region Trustmark Ins Trustmark Life Ins Co Tufts Health Plan UHC UHC UHC 30551 UHC 30555 UHC 30557 UHC 30990 UHC 659758 UHC 659759 UHC 659766 UHC 740800 UHC 740801 UHC 740802 UHC 740803 UHC 740810 UHC 740831 UHC 981502 UHC Klais And Company UHC Ky St UMR UMR UMR UMWA Health And Retirment Funds UMWA Health And Welfare Unicare 4458 Unicare 9090 Unicare/Medicare Adv Uniform Medical Plan Union Bankers Union Bankers Insurance Co Union Labor Life Insurance Co Union Pacific Railroad Employees HP United American Ins United American Insurance United Commercial Travelers Of America United Medical Resources United States Contractors Trust United Teacher Associates US Benefits Us Dept Of Labor USAA Life Insurance Company USAMCO USNOW LP VCP VSP VSP Medicaid Wabash Memorial Hosp Assoc Washinton National Insurance Co Wausau Wausau Benefits Wausau Benefits Wausau Insurance Companies Web-Tpa Web-Tpa Wellcare WellCare Medicaid Wells Fargo Insurance Western & Southern Financial Grou Westport Benefits Work Comp Mo Emply Mutu Worker Comp Ky School Boards Association Workers Comp Workers Comp-southern States Workers Comp Travelers Insurance Workers Comp URS Corporation World Insurance WPS
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 1st Sargeant Hedden 3M Safety Glasses AAG AARP Acordia National Administrative Concepts Inc Advantra Freedom Advantra GHP Aetna Aetna 1125 Aetna 14079 Aetna 14089 Aetna 14094 Aetna 14100 Aetna 14586 Aetna 30258 Aetna 795080 Aetna 981106 Aetna 981109 Aetna 981204 Aetna Medicare 981107 Aetna Medicare Pffs Aetna Us Healthcare AFLAC Aftra Health Fund AIG Accident & Health Clms Alicare Inc Local 161 Allied Benefit Systems Allied National/co Global Care Inc AMA Insurance American Adm Group Inc American Adm Group Inc American Continatial American Family Insurance American Heritage Life Insurance Company American Medical Security American Pioneer Life American Postal Workers Union American Progressive Claims American Republic Insurance Amerihealth Adm APAIE LOCAL 618 APWU APWU Health Plan ASRM Association & Society Ins Corp Assurant Health Aultcare Auto Insurance Auto Owners Insurance Avesis Avesis Medicaid AVMA Group Health Ball State University Baltas Vision Bankers Fidelity Bankers Life And Casualty Bankers Life And Casualty Co Bankers Life And Casualty Co BAS LLC Beech Street Corp Beechstreet Benefit Consultants Inc Benefit Management Services Inc Benefit Plan Adm Of Wisc Benefit Plan Management Benefit Planners Benefits Management Inc BeneScript BENESIGHT Best Life Block Vision Blue Choice Blue Cross and Blue Shield of Kentucky Blue Cross Blue Shield - Empire Blue Cross Blue Shield Of Illinois Blue Vision Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Wells Fargo TPA Bluegrass Network Bradford Square Bridgestone Americas, Inc. C L Frates And Company California Secure Horizons Capella Group Care Improvement Plus Care Management Resource CMR Care Management Resources Carpenters Health Welfare CBA CBS PERSONNEL CBSA Central Reserve Central States H&W Fund Central States Indemnity Central United Life Cerner Health CHA Champva Center Dept Of Treasury CHBA Chesterfield Resources Inc Chickering Claims Chickering Claims Adm Christian Brothers HMSR Christian Care Medi Share Christian Fidelity 44990 Christian Fidelity 5840 Cigna Cigna 15050 Cigna 182223 Cigna 3020 Cigna 3058 Cigna 5200 Cigna 55270 Cigna 62308 Cigna 997561 Cigna Healthcare 32894 Cigna Healthcare 5909 Cigna HMO CMI Colonial Penn Life Ins Combined Insurance Combined Insurance Co Commerce Benefits Group Clms Connecticut General Insurance Company Conseco Health Constitution Life Ins Continental American Ins Co Continental General Life Continental Life Cooperate Benifit Administrators Coresource 2920 Coresource 5200 Country Life Insurance Company Coventry Health Care 8400 Coventry Health Care 8401 Coventry Healthcare Of Kansas City CoventryCares Medicaid Davis Vision Deal Makers Auto Sales Of Frankfort Definity Health Plan Phcs Deseret Mutual Directpay Disability Management Diversified Adm Corporation EBA Employee Benefits Administrators Emerson Appliance Solutions Employment Plus Epoch Equitable Life Essence Medicare HMO Evercare Exclusive Choice EyeMed Farm Bureau Federated Claims Services First Health 24220 First Health 6249 First Health 8400 First Health 8401 First Health Direct First Health Network Fiserv Health 725 Fiserv Health 8031 Fiserv Health 8077 Fiserve Health-Kansas FMH Fore Thought Fortis Ins FRMC ER Coverage GE Health Manager GE Life And Annuity GEHA Genesis Health Plans GHP 7112 GHP 7121 GHP 7374 Global Excel Management Globe Life Gold Advantage Golden Living Golden Rule Insurance Grange Insurance Great West Life Assurance Company Group & Pension Adm Inc Guarantee Trust Guardian Harrington Benefits Hartford Ins Co/mediplus Hartford Life And Accident Haskell Health Center Health Alliance Medical Plans Health Benefit Plan Health Choices Health Plan Services Healthcare USA Healthfirst TPA Healthlink HMO Healthlink Open Access Healthlink PPO HealthPartners Claim Healthplus PPO Healthscope Benefits HealthSmart Preferred Care HealthStar HFN Inc HMSA BCBS HNA/FSC/CHCA HSI Health Strategic Init HSR Administrators Humana Humana Gold Choice Humana One Humana VCP IAC Illinois Medicaid Indiana State Council Of Roofers Insurers Adm Corp IUOE Local 513 James B. Haggin Memorial Hospital Johnston Companies/USA H&W Network JSL Administrators Inc K&K Insurance Kaiser Permanente Kentucky Access Kentucky Access Kentucky Disability Kentucky Spirit Medicaid KVP KY Office For Blind Liberty Mutual Ins Lincoln Heritage Life Ins Local 176 Health & Welfare Loomis Company SKF USA Lumenos Mail Handlers Benefit Mail Handlers Benefit Plan McGregor & Associates Med Link Healthcare Networks Inc Medben Medi-share Processing Center Medicaid Medical Mutual Medicare Complete Choice Medicare Complete/Secure Horizons Medicare DME Medicare Illinois Medicare Part B Cigna Government Service Medicare Railroad Medico Mega Life Mega Life And Health Insurance Company Mega Life Star Hrg Mercer Administration Mercy Careplus Mercy Health Plans Mercy Premier Plus Meritain Health Metlife Midwest Security Adm Inc Missouri Employers Mutual/MEMIC Monoplast Of North America Monoplast Of North America Monumental Life Insurance Company Mutual Of Omaha Mutual Of Omaha Mutual Of Omaha Co Mutual Of Omaha/Charlotte Center Mutual Protective MVP NALC NASI National Foundation Life Ins Co National States National Vision Administrators Nationwide Health Plans NEIHBP New Era Life Ins North American Administrators ODS Office For The Blind One Heath Plan Operating Engineers Local 513 Opticare OptiCare Medicaid Oxford Health Oxford Health Plans P5 Health Plans Solutions Pacific Source Health Plans Pacificare Pacificare Of Arizona Painters District 2 Welfare Passport Advantage Passport Health Plan Pekin Life Ins Pennsylvania Life Insurance Performax 27725 Performax 61505 PersonalCare Philadelphia American Life Phillips Administrative Service Inc Physicians Mutual Plan Administrative Incorporated PAI Plumbers & Pipefitters Local 562 PPOM Preferred Care Preferred Health Plan Preferred One Administrative Services Priests Mutual Benefit Primary PhysicianCare Inc Principal Financial Principal Life Insurance Company Principal Mutual Life Private Healthcare Systems 12170 Private Healthcare Systems 13845 Progressive Benefits Service Pyramid Claims Pyramid Life Quality Benefits Llc/claims Processing Reliance Standard Religious Comprehensive Trust Reserve National Insurance Retiree Medical Insurance Plan RMSCO Inc. Royal Neighbors Of America RR Medicare Safe Auto SAMBA Seabury And Smith ELCA Seven Corners Sheet Metal Local 36 Sheet Metal Workers/SMW+ Shelter Insurance Shenandoah Life Ins Co Sierra Health And Life Sisco Smith Administrators SOI Health Plan/First Health Network Southern Il Health Spectera Vision SS Healthcare Strategies St John's Claim Adm St Louis Graphic Arts Standard Life And Accident 1800 Standard Life And Accident 25097 Star HRG Starmark State Farm Health Ins 339403 State Farm Health Ins 9403 State Farm Ins State Mutual Insurance Sterling Life Ins Co Strategic Resource Co Superior Vision TCS Teamcare Teamsters Medicare Trust Local 688 The Benefit Group The Corps Network Thrivent Financial For Lutherans Time Insurance Tower Life Ins Co Travelers Construction Workers Comp Travelers Insurance Tricare North Region Trustmark Ins Trustmark Life Ins Co Tufts Health Plan UHC UHC UHC 30551 UHC 30555 UHC 30557 UHC 30990 UHC 659758 UHC 659759 UHC 659766 UHC 740800 UHC 740801 UHC 740802 UHC 740803 UHC 740810 UHC 740831 UHC 981502 UHC Klais And Company UHC Ky St UMR UMR UMR UMWA Health And Retirment Funds UMWA Health And Welfare Unicare 4458 Unicare 9090 Unicare/Medicare Adv Uniform Medical Plan Union Bankers Union Bankers Insurance Co Union Labor Life Insurance Co Union Pacific Railroad Employees HP United American Ins United American Insurance United Commercial Travelers Of America United Medical Resources United States Contractors Trust United Teacher Associates US Benefits Us Dept Of Labor USAA Life Insurance Company USAMCO USNOW LP VCP VSP VSP Medicaid Wabash Memorial Hosp Assoc Washinton National Insurance Co Wausau Wausau Benefits Wausau Benefits Wausau Insurance Companies Web-Tpa Web-Tpa Wellcare WellCare Medicaid Wells Fargo Insurance Western & Southern Financial Grou Westport Benefits Work Comp Mo Emply Mutu Worker Comp Ky School Boards Association Workers Comp Workers Comp-southern States Workers Comp Travelers Insurance Workers Comp URS Corporation World Insurance WPS
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 1st Sargeant Hedden 3M Safety Glasses AAG AARP Acordia National Administrative Concepts Inc Advantra Freedom Advantra GHP Aetna Aetna 1125 Aetna 14079 Aetna 14089 Aetna 14094 Aetna 14100 Aetna 14586 Aetna 30258 Aetna 795080 Aetna 981106 Aetna 981109 Aetna 981204 Aetna Medicare 981107 Aetna Medicare Pffs Aetna Us Healthcare AFLAC Aftra Health Fund AIG Accident & Health Clms Alicare Inc Local 161 Allied Benefit Systems Allied National/co Global Care Inc AMA Insurance American Adm Group Inc American Adm Group Inc American Continatial American Family Insurance American Heritage Life Insurance Company American Medical Security American Pioneer Life American Postal Workers Union American Progressive Claims American Republic Insurance Amerihealth Adm APAIE LOCAL 618 APWU APWU Health Plan ASRM Association & Society Ins Corp Assurant Health Aultcare Auto Insurance Auto Owners Insurance Avesis Avesis Medicaid AVMA Group Health Ball State University Baltas Vision Bankers Fidelity Bankers Life And Casualty Bankers Life And Casualty Co Bankers Life And Casualty Co BAS LLC Beech Street Corp Beechstreet Benefit Consultants Inc Benefit Management Services Inc Benefit Plan Adm Of Wisc Benefit Plan Management Benefit Planners Benefits Management Inc BeneScript BENESIGHT Best Life Block Vision Blue Choice Blue Cross and Blue Shield of Kentucky Blue Cross Blue Shield - Empire Blue Cross Blue Shield Of Illinois Blue Vision Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Bluegrass Family Health Wells Fargo TPA Bluegrass Network Bradford Square Bridgestone Americas, Inc. C L Frates And Company California Secure Horizons Capella Group Care Improvement Plus Care Management Resource CMR Care Management Resources Carpenters Health Welfare CBA CBS PERSONNEL CBSA Central Reserve Central States H&W Fund Central States Indemnity Central United Life Cerner Health CHA Champva Center Dept Of Treasury CHBA Chesterfield Resources Inc Chickering Claims Chickering Claims Adm Christian Brothers HMSR Christian Care Medi Share Christian Fidelity 44990 Christian Fidelity 5840 Cigna Cigna 15050 Cigna 182223 Cigna 3020 Cigna 3058 Cigna 5200 Cigna 55270 Cigna 62308 Cigna 997561 Cigna Healthcare 32894 Cigna Healthcare 5909 Cigna HMO CMI Colonial Penn Life Ins Combined Insurance Combined Insurance Co Commerce Benefits Group Clms Connecticut General Insurance Company Conseco Health Constitution Life Ins Continental American Ins Co Continental General Life Continental Life Cooperate Benifit Administrators Coresource 2920 Coresource 5200 Country Life Insurance Company Coventry Health Care 8400 Coventry Health Care 8401 Coventry Healthcare Of Kansas City CoventryCares Medicaid Davis Vision Deal Makers Auto Sales Of Frankfort Definity Health Plan Phcs Deseret Mutual Directpay Disability Management Diversified Adm Corporation EBA Employee Benefits Administrators Emerson Appliance Solutions Employment Plus Epoch Equitable Life Essence Medicare HMO Evercare Exclusive Choice EyeMed Farm Bureau Federated Claims Services First Health 24220 First Health 6249 First Health 8400 First Health 8401 First Health Direct First Health Network Fiserv Health 725 Fiserv Health 8031 Fiserv Health 8077 Fiserve Health-Kansas FMH Fore Thought Fortis Ins FRMC ER Coverage GE Health Manager GE Life And Annuity GEHA Genesis Health Plans GHP 7112 GHP 7121 GHP 7374 Global Excel Management Globe Life Gold Advantage Golden Living Golden Rule Insurance Grange Insurance Great West Life Assurance Company Group & Pension Adm Inc Guarantee Trust Guardian Harrington Benefits Hartford Ins Co/mediplus Hartford Life And Accident Haskell Health Center Health Alliance Medical Plans Health Benefit Plan Health Choices Health Plan Services Healthcare USA Healthfirst TPA Healthlink HMO Healthlink Open Access Healthlink PPO HealthPartners Claim Healthplus PPO Healthscope Benefits HealthSmart Preferred Care HealthStar HFN Inc HMSA BCBS HNA/FSC/CHCA HSI Health Strategic Init HSR Administrators Humana Humana Gold Choice Humana One Humana VCP IAC Illinois Medicaid Indiana State Council Of Roofers Insurers Adm Corp IUOE Local 513 James B. Haggin Memorial Hospital Johnston Companies/USA H&W Network JSL Administrators Inc K&K Insurance Kaiser Permanente Kentucky Access Kentucky Access Kentucky Disability Kentucky Spirit Medicaid KVP KY Office For Blind Liberty Mutual Ins Lincoln Heritage Life Ins Local 176 Health & Welfare Loomis Company SKF USA Lumenos Mail Handlers Benefit Mail Handlers Benefit Plan McGregor & Associates Med Link Healthcare Networks Inc Medben Medi-share Processing Center Medicaid Medical Mutual Medicare Complete Choice Medicare Complete/Secure Horizons Medicare DME Medicare Illinois Medicare Part B Cigna Government Service Medicare Railroad Medico Mega Life Mega Life And Health Insurance Company Mega Life Star Hrg Mercer Administration Mercy Careplus Mercy Health Plans Mercy Premier Plus Meritain Health Metlife Midwest Security Adm Inc Missouri Employers Mutual/MEMIC Monoplast Of North America Monoplast Of North America Monumental Life Insurance Company Mutual Of Omaha Mutual Of Omaha Mutual Of Omaha Co Mutual Of Omaha/Charlotte Center Mutual Protective MVP NALC NASI National Foundation Life Ins Co National States National Vision Administrators Nationwide Health Plans NEIHBP New Era Life Ins North American Administrators ODS Office For The Blind One Heath Plan Operating Engineers Local 513 Opticare OptiCare Medicaid Oxford Health Oxford Health Plans P5 Health Plans Solutions Pacific Source Health Plans Pacificare Pacificare Of Arizona Painters District 2 Welfare Passport Advantage Passport Health Plan Pekin Life Ins Pennsylvania Life Insurance Performax 27725 Performax 61505 PersonalCare Philadelphia American Life Phillips Administrative Service Inc Physicians Mutual Plan Administrative Incorporated PAI Plumbers & Pipefitters Local 562 PPOM Preferred Care Preferred Health Plan Preferred One Administrative Services Priests Mutual Benefit Primary PhysicianCare Inc Principal Financial Principal Life Insurance Company Principal Mutual Life Private Healthcare Systems 12170 Private Healthcare Systems 13845 Progressive Benefits Service Pyramid Claims Pyramid Life Quality Benefits Llc/claims Processing Reliance Standard Religious Comprehensive Trust Reserve National Insurance Retiree Medical Insurance Plan RMSCO Inc. Royal Neighbors Of America RR Medicare Safe Auto SAMBA Seabury And Smith ELCA Seven Corners Sheet Metal Local 36 Sheet Metal Workers/SMW+ Shelter Insurance Shenandoah Life Ins Co Sierra Health And Life Sisco Smith Administrators SOI Health Plan/First Health Network Southern Il Health Spectera Vision SS Healthcare Strategies St John's Claim Adm St Louis Graphic Arts Standard Life And Accident 1800 Standard Life And Accident 25097 Star HRG Starmark State Farm Health Ins 339403 State Farm Health Ins 9403 State Farm Ins State Mutual Insurance Sterling Life Ins Co Strategic Resource Co Superior Vision TCS Teamcare Teamsters Medicare Trust Local 688 The Benefit Group The Corps Network Thrivent Financial For Lutherans Time Insurance Tower Life Ins Co Travelers Construction Workers Comp Travelers Insurance Tricare North Region Trustmark Ins Trustmark Life Ins Co Tufts Health Plan UHC UHC UHC 30551 UHC 30555 UHC 30557 UHC 30990 UHC 659758 UHC 659759 UHC 659766 UHC 740800 UHC 740801 UHC 740802 UHC 740803 UHC 740810 UHC 740831 UHC 981502 UHC Klais And Company UHC Ky St UMR UMR UMR UMWA Health And Retirment Funds UMWA Health And Welfare Unicare 4458 Unicare 9090 Unicare/Medicare Adv Uniform Medical Plan Union Bankers Union Bankers Insurance Co Union Labor Life Insurance Co Union Pacific Railroad Employees HP United American Ins United American Insurance United Commercial Travelers Of America United Medical Resources United States Contractors Trust United Teacher Associates US Benefits Us Dept Of Labor USAA Life Insurance Company USAMCO USNOW LP VCP VSP VSP Medicaid Wabash Memorial Hosp Assoc Washinton National Insurance Co Wausau Wausau Benefits Wausau Benefits Wausau Insurance Companies Web-Tpa Web-Tpa Wellcare WellCare Medicaid Wells Fargo Insurance Western & Southern Financial Grou Westport Benefits Work Comp Mo Emply Mutu Worker Comp Ky School Boards Association Workers Comp Workers Comp-southern States Workers Comp Travelers Insurance Workers Comp URS Corporation World Insurance WPS
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

Medical Problems:
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+ 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

Injuries, Surgeries, Hospitalization

None Other

Pregnant Or Nursing:
No Yes Unsure Other	Notes:

Last Visit:

1 week 1 month 3 months 6 months 1 year 2 years Other

OTC:

None Asprin Acetomenophin Ibuprofen Other

Vitamins:

None A E C Zinc Xanten Lutein Other

Family History	Relationship
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other	Mother Father Brother Sister Grandmother Grandfather Uncle Aunt Cousin Child If other, please type in this box.
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other	Mother Father Brother Sister Grandmother Grandfather Uncle Aunt Cousin Child If other, please type in this box.
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other	Mother Father Brother Sister Grandmother Grandfather Uncle Aunt Cousin Child If other, please type in this box.
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other	Mother Father Brother Sister Grandmother Grandfather Uncle Aunt Cousin Child If other, please type in this box.
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other	Mother Father Brother Sister Grandmother Grandfather Uncle Aunt Cousin Child If other, please type in this box.
None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other	Mother Father Brother Sister Grandmother Grandfather Uncle Aunt Cousin Child If other, please type in this box.

Race:	Language:	Ethnicity:
American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Decline	English Spanish French Decline Arabic German French If other, please type in this box.	Hispanic or Latino Not Hispanic or Latino Unknown Decline

Occupation:	Hobbies:
Student Police officer Teacher Nurse Salesman Firefighter Engineer Other	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

Smoking Status:	Type:	How Long:
Never Smoker Current every day smoker Current some day smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked Other	None Cigaretts Chewing Tobacco Other

Alcohol:	Type:	How Long:
No Yes Occasionally Socially Other	None Beer Wine Hard Liquor Other

>

Illegal Drugs:	Type:	How Long:	STD:
No Yes Other			None Gonorrhea Syphilis Hepatitis HIV TB Other

NKDANo current meds >

Ocular History
Disease	Eye	When	Procedure
1 None Cataract Glaucoma Macular Degeneration Retinal Detachment Amblyopia(Lazy Eye)	Right Eye Left Eye Both Eyes	Within last 6 months Between 6 months-1year Between 1-5years Between 5-15years ago more than 15 years ago	None Cataract Surgery Glaucoma Surgery Eyelid Surgery Lasik Surgery(for getting rid of glasses) Laser Treatment (YAG-after cataract suergery) Laser Treatment (for glaucoma) Laser Treatment (Retina laser for diabetes) Laser Treatment (unknown)
2 None Cataract Glaucoma Macular Degeneration Retinal Detachment Amblyopia(Lazy Eye)	Right Eye Left Eye Both Eyes	Within last 6 months Between 6 months-1year Between 1-5years Between 5-15years ago more than 15 years ago	None Cataract Surgery Glaucoma Surgery Eyelid Surgery Lasik Surgery(for getting rid of glasses) Laser Treatment (YAG-after cataract suergery) Laser Treatment (for glaucoma) Laser Treatment (Retina laser for diabetes) Laser Treatment (unknown)
3 None Cataract Glaucoma Macular Degeneration Retinal Detachment Amblyopia(Lazy Eye)	Right Eye Left Eye Both Eyes	Within last 6 months Between 6 months-1year Between 1-5years Between 5-15years ago more than 15 years ago	None Cataract Surgery Glaucoma Surgery Eyelid Surgery Lasik Surgery(for getting rid of glasses) Laser Treatment (YAG-after cataract suergery) Laser Treatment (for glaucoma) Laser Treatment (Retina laser for diabetes) Laser Treatment (unknown)
4 None Cataract Glaucoma Macular Degeneration Retinal Detachment Amblyopia(Lazy Eye)	Right Eye Left Eye Both Eyes	Within last 6 months Between 6 months-1year Between 1-5years Between 5-15years ago more than 15 years ago	None Cataract Surgery Glaucoma Surgery Eyelid Surgery Lasik Surgery(for getting rid of glasses) Laser Treatment (YAG-after cataract suergery) Laser Treatment (for glaucoma) Laser Treatment (Retina laser for diabetes) Laser Treatment (unknown)
5 None Cataract Glaucoma Macular Degeneration Retinal Detachment Amblyopia(Lazy Eye)	Right Eye Left Eye Both Eyes	Within last 6 months Between 6 months-1year Between 1-5years Between 5-15years ago more than 15 years ago	None Cataract Surgery Glaucoma Surgery Eyelid Surgery Lasik Surgery(for getting rid of glasses) Laser Treatment (YAG-after cataract suergery) Laser Treatment (for glaucoma) Laser Treatment (Retina laser for diabetes) Laser Treatment (unknown)

Medication List
Medication	Dosage	Month/Year Prescribed
1
2
3
4
5

Review of Systems

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

GENERAL: Fever, weight loss, weight gain, fatigue?	None Negative Fever Weight loss Weight gain Fatigue
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 Vascular Disease HBP Heart Surgery
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: Arthritis, 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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