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Patient Information

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

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 #

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Billing Information

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

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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

Insurance Information

Insurance Name:	None AARP Health Care Options AARP(Washington, DC) AARP/ Medicare Supp Plan/United HealthCare AARP/MEDICARE COMPLETE Accident Fund Accident fund Insurance Company of America Admiral Life Ins Comp Of America Advantica Eye Care Advantra Advantra Freedom Aetna (Greensboro,NC) AETNA (Lexington, KY) Aetna (ElPaso, TX) Aetna (Grand Rapids, MI) Aetna (Lubbock , TX) Aetna Coventry Aetna Health Plans (Windsor, CT) Aetna Insurance Co. (Ft. Wayne, IN) Aetna Insurance Co. (Overland Park, KS) Aetna Life Ins Comp (Toledo, OH) Aetna Life Insurance Co. (Hartford, CT) Aetna Life Insurance Co. (Ok City, OK) Aetna Life Insurance Company Aetna Medicare PDP (Phoenix, AZ) Aetna Medicare PPO AETNA Medicare PPO Aetna Signature Administrators Aetna US Healthcare (Kansas City, MO) Aflac All Savers Allwell From Home State Ambetter From Home State Health AMCO America's Choice Healthplans American Continental Insurance Company American Family Insurance American Family Mutual American Healthcare Alliance American Medical Security American National American Pioneer American Republic Insurance Americas Choice Ameritas Life Ins Anthem Blue Cross/Blue Shield Anthem MediBlue Access (PPO) Anthem MediBlue Plus (HMO) Anthem Medicare Advantage PFFS Anthem Medicare Preferred Care (PPO) APWU Health PLan Arkansas Blue Cross BlueShield Arkansas Blue Cross BlueShield (Medipak Adv) PFFS Assurant Avesis Avesis Third Party Admin Avesis Third Party Vision Claims AVMA Group Health & Life Bankers Fidelity Bankers Life and Casualty BC/BS Medicare PLUS Blue Group PPO Bearskin Healthcare & Wellness Center Benchmark Insurance Co. Benchmark Insurance Co. Benefit Administrators Benefit Management Benefit Management, Inc. Benefit Trust Life Ins. Co. BerkleyNet Underwriters BLUE CROSS / BLUE SHIELD FED Blue Cross BlueShield BMI Health Plans Boilmakers Nat Health & Welfare Fund Boilmakers Nat Health & Welfare Fund (PO Box 219118) Boilmakers Vision Bridge Pointe Broadspire Services Care Improvement Plus (Linthicum, MD) Care To Learn Caremark Claims Dept Carpenters Health & Welfare Trust Fund CCO, Inc Celtic Individual Celtic Individual Health CENTRAL STATES Central States Heatlth & Life Co. of Omaha Central States, S.E. & S. W. Areas Champus CHAMPVA Childrens Miracle Network Christian Fidelity Cigna (Chattanooga, TN) Cigna Global Cigna Medicare Access Plus Cigna Medicare Supplement Solutions Cigna Vision CNA Cole Managed Vision Colonial Penn Life Insurance Combined Insurance Company of America Companion Life COMPNAME Connecticut General Life Conseco Ins Company Consolidated Group Claims Consolidated Group Claims Constitution Life Ins Comp Construction Ind. Laborers Construction Industy laborers Welfare Fund Continental Assurance Co. Continental General Continental General Continental Life Insurance Cooperative Benefit Center CorVel Coventry / Medicare Advantage Plans Coventry / MoDot/MSHP Coventry / University of Missouri Claims Coventry Health Care Coventry One Cox Health Systems CRA Managed Care, Inc. Dakotas & Western Benefits Admin Davis Vision Definity Health Disability Determinations Division of Family Services EFCO Corporation Epoch Group,LC Equicor, Inc. Equitable Life & Casualty Equitable Plan Services Esis Essence Healthcare Evercare Everence Everest Eyeconic EyeMed EyeQuest Family Support Division Farmers Insurance Exchange Federated Mutual Insurance Co. First Choice Administrators First Continental Life & Accident Insurance Co. First Health First Health (Federated) First Health Network / Starmark First Health Part D / Medico First Steps Fiser V Health Floricda Medicaid FMH Benefit Services FMH/Heath Link Foreign Mission Board Fortis Benefits Fortis Benefits Ins Co. Fortis Benefits Insurance Co. Freedom Blue PPO Freedom Network Select GE Medicare Benefit Plans GEHA General American Life General American Life General Casualty Golden Rule Ins Co Gov't Employees Health Assc GPM Life Great West (Cheyenne,WY) Great West (Kennett, MO) Greene County Children's Division Grinnell Mutual Reinsurance Co. Group Health Plan Guarantee Trust Life Ins. Company Guardian GWH- Cigna Harden & Company Harrington Southwest HCH Administrators health Health Insurance Innovations Co-Ord Ben Plans Health Link Open Access Health Link/Freedom (PO Box 419104) Health Link/HSB HealthCare Solutions Group HealthChoice HealthFlex Healthlink/ Christian Brothers HealthScope HealthSmart Benefit Solutions Healthsmart Preferred Care, Inc. Healthy Alliance Life Ins. Co. Highmark / Freedom Blue PPO Hillcrest Benefit Administrator HIP Home State Health Care (MCD) HSI Benefit Systems Humana Choice PPO Humana Claims Humana Connect Medicare Supplement Humana Gold Choice Humana Gold Plus HMO (Box 14601, Lexington KY) Humana Insurance Co. Humana Medicare PPO Humana, Inc. IAC IMG Indiana Laboreres Welfare Fund Insurance Admin Solutions Insurance Managemant Admin John Alden Life Insurance Co. Laborers Health & Welfare LaHood and Associates Life Investors Insurance Lions Club Mail Handlers Benefit Plan Manhattan Life Ins Marathon Electric Marquette National Mass Mutual Mattax-Neu-Prater Med Benefit Systems Med Pay Med Plans 2000 Medco Medica Medical-Cigna Healthcare Medical Review Team Medicare Supplement Operations Medico Medifit Insurance Medishare Medivest Meeks Building-Med Pay Mercer Mercy Benefits Administrators Mercy Medicare Advantage HMO-POS Mercy Medicare Advantage (PPO) Meritain Health ( Minneapolis, MN) Meritain Health (Richardson, TX) Metropolitan Life Insurance Missouri Employee Mutual Ins Missouri Employers Mutual Missouri Eye Institute Missouri Healthnet Missouri Valley Mo-Kan Sheet Metal Workers Welfare Fund MO Care Health Plan(MCD) MoDOT/MSHP Claims Molina Healthcare Monumental Life Mosers/Humana MSC MSTA Claims Unit Municipal Health Benefit Fund Mutual Assurance Adninistrators Mutual of Omaha National Automatic Sprinkler Industry National Travelers Life Nationwide Specialty Health Claims NEI New Era Life Insurance Company New Insurance NHP Group Limited Benefit Claims Nordian Administrative Services North American Ins. Co. NVA Oklahoma State & Education Employees Old Surety Life Ins Comp Omaha Insurance Company OptumHealth Vision Claims Dept Oxford Life Ins Ozark Health Plan Painters District Council #2 Welfare Plan Paradigm Mangement Serives, LLC Pension Associates PHCS Physicians Mutual Pioneer Life Preferred Health Professionals Premier Plus HMO Premier Plus Options Prevention of Blindness Principal (Clearwater, FL) Principal Financial Group Principal Health Care, Inc. Principal Life Ins Dental/Vision Principal LIfe Insurance Co. (Colorado Springs) Principal Mutual Group Principal Mutual Insurance Co. Principal Mutual Life Principle Health Care, Inc-PPO Professional Benefit Admin. Provident Insurance Co. Provident Life and Accident Provident Life and Accident Prudential Custom Care Pyramid Claims QBE Qual Choice RCBA/Healthlink Rehab Services F/T Blind Reserve National Insurance Co. Restat Roebuck Administrators, Inc. Royal Neighbors of America Seabright Insurance Secure Horizons Security Life InsuranceCo. Sheet Metals Workers Local 104 Spectera St Johns Claims Admin Standard Life & Accident Ins Starmark State Farm Health Insurance State Mutual Life Assurance Sterling Investors Life Ins Comp Stonebridge Life Superior Vision TCS Team Care The Federated Insurance Co. The Guardian Insurance Co. The Hartford The Principal Financial Group The Principal Financial Group The Principal Mutual Group The Travelers-P-C Claim Dept The Travelers Consolidated The Travelers Insurance Co. Thrivent Financial for Lutherans TIC International Corp Time Ins Co Time Insurance Co. Today's Options / Pyramid Life Trans American Life Traveler's (Work Comp) Travelers Insurance Tricare For Life Tricare West Region Claims TriWest Healthcare Alliance UFCW Food Trades & Indust. Health & Welfare UGS- Global Care, Inc. UMR UMR Unicare Union Bankers United American Insurance Company United Health Care United Health Care (El Paso, TX) United Health Care Community Plan United Health Care Dual Complete / Sr Medicare Adv United Healthcare (Atlanta) United Healthcare (Salt Lake)(PO Box 30555) UNITED HEALTHCARE / CARE IMPROVEMENT United Healthcare / Medicare Solutions/Medicare Advantage United Healthcare Medicare Direct United Healthcare Midwest (MCD) UNITED HEALTHCARE SHARED SERVICES United Healthcare Vision United Teacher Assc.(Austin, TX) United World LIfe Ins USA MCO H&W Network USAA Life Insurance Company USAble Life Group Health Veterans Administration / VISN 16 Consolidated Fee Unit Vision USA VisionUSA Vocational Rehabilitation VSP VSP/ ASPEX FRAME CLAIMS Wakely & Associates, Inc. Washington National (Lincolnshire, IL) Washington National (Phoenix, AZ) Washington National Insurance Company (Carmel, IN) Wausau Insurance Co. Wellcare Concert PFFS Plan WellCare PFFS Western Teamsters Welfare Trust Westport Benefits(St.Loius) Worldwide Insurance WPS Medicare Part B Zurich North America
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 Health Care Options AARP(Washington, DC) AARP/ Medicare Supp Plan/United HealthCare AARP/MEDICARE COMPLETE Accident Fund Accident fund Insurance Company of America Admiral Life Ins Comp Of America Advantica Eye Care Advantra Advantra Freedom Aetna (Greensboro,NC) AETNA (Lexington, KY) Aetna (ElPaso, TX) Aetna (Grand Rapids, MI) Aetna (Lubbock , TX) Aetna Coventry Aetna Health Plans (Windsor, CT) Aetna Insurance Co. (Ft. Wayne, IN) Aetna Insurance Co. (Overland Park, KS) Aetna Life Ins Comp (Toledo, OH) Aetna Life Insurance Co. (Hartford, CT) Aetna Life Insurance Co. (Ok City, OK) Aetna Life Insurance Company Aetna Medicare PDP (Phoenix, AZ) Aetna Medicare PPO AETNA Medicare PPO Aetna Signature Administrators Aetna US Healthcare (Kansas City, MO) Aflac All Savers Allwell From Home State Ambetter From Home State Health AMCO America's Choice Healthplans American Continental Insurance Company American Family Insurance American Family Mutual American Healthcare Alliance American Medical Security American National American Pioneer American Republic Insurance Americas Choice Ameritas Life Ins Anthem Blue Cross/Blue Shield Anthem MediBlue Access (PPO) Anthem MediBlue Plus (HMO) Anthem Medicare Advantage PFFS Anthem Medicare Preferred Care (PPO) APWU Health PLan Arkansas Blue Cross BlueShield Arkansas Blue Cross BlueShield (Medipak Adv) PFFS Assurant Avesis Avesis Third Party Admin Avesis Third Party Vision Claims AVMA Group Health & Life Bankers Fidelity Bankers Life and Casualty BC/BS Medicare PLUS Blue Group PPO Bearskin Healthcare & Wellness Center Benchmark Insurance Co. Benchmark Insurance Co. Benefit Administrators Benefit Management Benefit Management, Inc. Benefit Trust Life Ins. Co. BerkleyNet Underwriters BLUE CROSS / BLUE SHIELD FED Blue Cross BlueShield BMI Health Plans Boilmakers Nat Health & Welfare Fund Boilmakers Nat Health & Welfare Fund (PO Box 219118) Boilmakers Vision Bridge Pointe Broadspire Services Care Improvement Plus (Linthicum, MD) Care To Learn Caremark Claims Dept Carpenters Health & Welfare Trust Fund CCO, Inc Celtic Individual Celtic Individual Health CENTRAL STATES Central States Heatlth & Life Co. of Omaha Central States, S.E. & S. W. Areas Champus CHAMPVA Childrens Miracle Network Christian Fidelity Cigna (Chattanooga, TN) Cigna Global Cigna Medicare Access Plus Cigna Medicare Supplement Solutions Cigna Vision CNA Cole Managed Vision Colonial Penn Life Insurance Combined Insurance Company of America Companion Life COMPNAME Connecticut General Life Conseco Ins Company Consolidated Group Claims Consolidated Group Claims Constitution Life Ins Comp Construction Ind. Laborers Construction Industy laborers Welfare Fund Continental Assurance Co. Continental General Continental General Continental Life Insurance Cooperative Benefit Center CorVel Coventry / Medicare Advantage Plans Coventry / MoDot/MSHP Coventry / University of Missouri Claims Coventry Health Care Coventry One Cox Health Systems CRA Managed Care, Inc. Dakotas & Western Benefits Admin Davis Vision Definity Health Disability Determinations Division of Family Services EFCO Corporation Epoch Group,LC Equicor, Inc. Equitable Life & Casualty Equitable Plan Services Esis Essence Healthcare Evercare Everence Everest Eyeconic EyeMed EyeQuest Family Support Division Farmers Insurance Exchange Federated Mutual Insurance Co. First Choice Administrators First Continental Life & Accident Insurance Co. First Health First Health (Federated) First Health Network / Starmark First Health Part D / Medico First Steps Fiser V Health Floricda Medicaid FMH Benefit Services FMH/Heath Link Foreign Mission Board Fortis Benefits Fortis Benefits Ins Co. Fortis Benefits Insurance Co. Freedom Blue PPO Freedom Network Select GE Medicare Benefit Plans GEHA General American Life General American Life General Casualty Golden Rule Ins Co Gov't Employees Health Assc GPM Life Great West (Cheyenne,WY) Great West (Kennett, MO) Greene County Children's Division Grinnell Mutual Reinsurance Co. Group Health Plan Guarantee Trust Life Ins. Company Guardian GWH- Cigna Harden & Company Harrington Southwest HCH Administrators health Health Insurance Innovations Co-Ord Ben Plans Health Link Open Access Health Link/Freedom (PO Box 419104) Health Link/HSB HealthCare Solutions Group HealthChoice HealthFlex Healthlink/ Christian Brothers HealthScope HealthSmart Benefit Solutions Healthsmart Preferred Care, Inc. Healthy Alliance Life Ins. Co. Highmark / Freedom Blue PPO Hillcrest Benefit Administrator HIP Home State Health Care (MCD) HSI Benefit Systems Humana Choice PPO Humana Claims Humana Connect Medicare Supplement Humana Gold Choice Humana Gold Plus HMO (Box 14601, Lexington KY) Humana Insurance Co. Humana Medicare PPO Humana, Inc. IAC IMG Indiana Laboreres Welfare Fund Insurance Admin Solutions Insurance Managemant Admin John Alden Life Insurance Co. Laborers Health & Welfare LaHood and Associates Life Investors Insurance Lions Club Mail Handlers Benefit Plan Manhattan Life Ins Marathon Electric Marquette National Mass Mutual Mattax-Neu-Prater Med Benefit Systems Med Pay Med Plans 2000 Medco Medica Medical-Cigna Healthcare Medical Review Team Medicare Supplement Operations Medico Medifit Insurance Medishare Medivest Meeks Building-Med Pay Mercer Mercy Benefits Administrators Mercy Medicare Advantage HMO-POS Mercy Medicare Advantage (PPO) Meritain Health ( Minneapolis, MN) Meritain Health (Richardson, TX) Metropolitan Life Insurance Missouri Employee Mutual Ins Missouri Employers Mutual Missouri Eye Institute Missouri Healthnet Missouri Valley Mo-Kan Sheet Metal Workers Welfare Fund MO Care Health Plan(MCD) MoDOT/MSHP Claims Molina Healthcare Monumental Life Mosers/Humana MSC MSTA Claims Unit Municipal Health Benefit Fund Mutual Assurance Adninistrators Mutual of Omaha National Automatic Sprinkler Industry National Travelers Life Nationwide Specialty Health Claims NEI New Era Life Insurance Company New Insurance NHP Group Limited Benefit Claims Nordian Administrative Services North American Ins. Co. NVA Oklahoma State & Education Employees Old Surety Life Ins Comp Omaha Insurance Company OptumHealth Vision Claims Dept Oxford Life Ins Ozark Health Plan Painters District Council #2 Welfare Plan Paradigm Mangement Serives, LLC Pension Associates PHCS Physicians Mutual Pioneer Life Preferred Health Professionals Premier Plus HMO Premier Plus Options Prevention of Blindness Principal (Clearwater, FL) Principal Financial Group Principal Health Care, Inc. Principal Life Ins Dental/Vision Principal LIfe Insurance Co. (Colorado Springs) Principal Mutual Group Principal Mutual Insurance Co. Principal Mutual Life Principle Health Care, Inc-PPO Professional Benefit Admin. Provident Insurance Co. Provident Life and Accident Provident Life and Accident Prudential Custom Care Pyramid Claims QBE Qual Choice RCBA/Healthlink Rehab Services F/T Blind Reserve National Insurance Co. Restat Roebuck Administrators, Inc. Royal Neighbors of America Seabright Insurance Secure Horizons Security Life InsuranceCo. Sheet Metals Workers Local 104 Spectera St Johns Claims Admin Standard Life & Accident Ins Starmark State Farm Health Insurance State Mutual Life Assurance Sterling Investors Life Ins Comp Stonebridge Life Superior Vision TCS Team Care The Federated Insurance Co. The Guardian Insurance Co. The Hartford The Principal Financial Group The Principal Financial Group The Principal Mutual Group The Travelers-P-C Claim Dept The Travelers Consolidated The Travelers Insurance Co. Thrivent Financial for Lutherans TIC International Corp Time Ins Co Time Insurance Co. Today's Options / Pyramid Life Trans American Life Traveler's (Work Comp) Travelers Insurance Tricare For Life Tricare West Region Claims TriWest Healthcare Alliance UFCW Food Trades & Indust. Health & Welfare UGS- Global Care, Inc. UMR UMR Unicare Union Bankers United American Insurance Company United Health Care United Health Care (El Paso, TX) United Health Care Community Plan United Health Care Dual Complete / Sr Medicare Adv United Healthcare (Atlanta) United Healthcare (Salt Lake)(PO Box 30555) UNITED HEALTHCARE / CARE IMPROVEMENT United Healthcare / Medicare Solutions/Medicare Advantage United Healthcare Medicare Direct United Healthcare Midwest (MCD) UNITED HEALTHCARE SHARED SERVICES United Healthcare Vision United Teacher Assc.(Austin, TX) United World LIfe Ins USA MCO H&W Network USAA Life Insurance Company USAble Life Group Health Veterans Administration / VISN 16 Consolidated Fee Unit Vision USA VisionUSA Vocational Rehabilitation VSP VSP/ ASPEX FRAME CLAIMS Wakely & Associates, Inc. Washington National (Lincolnshire, IL) Washington National (Phoenix, AZ) Washington National Insurance Company (Carmel, IN) Wausau Insurance Co. Wellcare Concert PFFS Plan WellCare PFFS Western Teamsters Welfare Trust Westport Benefits(St.Loius) Worldwide Insurance WPS Medicare Part B Zurich North America
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 Health Care Options AARP(Washington, DC) AARP/ Medicare Supp Plan/United HealthCare AARP/MEDICARE COMPLETE Accident Fund Accident fund Insurance Company of America Admiral Life Ins Comp Of America Advantica Eye Care Advantra Advantra Freedom Aetna (Greensboro,NC) AETNA (Lexington, KY) Aetna (ElPaso, TX) Aetna (Grand Rapids, MI) Aetna (Lubbock , TX) Aetna Coventry Aetna Health Plans (Windsor, CT) Aetna Insurance Co. (Ft. Wayne, IN) Aetna Insurance Co. (Overland Park, KS) Aetna Life Ins Comp (Toledo, OH) Aetna Life Insurance Co. (Hartford, CT) Aetna Life Insurance Co. (Ok City, OK) Aetna Life Insurance Company Aetna Medicare PDP (Phoenix, AZ) Aetna Medicare PPO AETNA Medicare PPO Aetna Signature Administrators Aetna US Healthcare (Kansas City, MO) Aflac All Savers Allwell From Home State Ambetter From Home State Health AMCO America's Choice Healthplans American Continental Insurance Company American Family Insurance American Family Mutual American Healthcare Alliance American Medical Security American National American Pioneer American Republic Insurance Americas Choice Ameritas Life Ins Anthem Blue Cross/Blue Shield Anthem MediBlue Access (PPO) Anthem MediBlue Plus (HMO) Anthem Medicare Advantage PFFS Anthem Medicare Preferred Care (PPO) APWU Health PLan Arkansas Blue Cross BlueShield Arkansas Blue Cross BlueShield (Medipak Adv) PFFS Assurant Avesis Avesis Third Party Admin Avesis Third Party Vision Claims AVMA Group Health & Life Bankers Fidelity Bankers Life and Casualty BC/BS Medicare PLUS Blue Group PPO Bearskin Healthcare & Wellness Center Benchmark Insurance Co. Benchmark Insurance Co. Benefit Administrators Benefit Management Benefit Management, Inc. Benefit Trust Life Ins. Co. BerkleyNet Underwriters BLUE CROSS / BLUE SHIELD FED Blue Cross BlueShield BMI Health Plans Boilmakers Nat Health & Welfare Fund Boilmakers Nat Health & Welfare Fund (PO Box 219118) Boilmakers Vision Bridge Pointe Broadspire Services Care Improvement Plus (Linthicum, MD) Care To Learn Caremark Claims Dept Carpenters Health & Welfare Trust Fund CCO, Inc Celtic Individual Celtic Individual Health CENTRAL STATES Central States Heatlth & Life Co. of Omaha Central States, S.E. & S. W. Areas Champus CHAMPVA Childrens Miracle Network Christian Fidelity Cigna (Chattanooga, TN) Cigna Global Cigna Medicare Access Plus Cigna Medicare Supplement Solutions Cigna Vision CNA Cole Managed Vision Colonial Penn Life Insurance Combined Insurance Company of America Companion Life COMPNAME Connecticut General Life Conseco Ins Company Consolidated Group Claims Consolidated Group Claims Constitution Life Ins Comp Construction Ind. Laborers Construction Industy laborers Welfare Fund Continental Assurance Co. Continental General Continental General Continental Life Insurance Cooperative Benefit Center CorVel Coventry / Medicare Advantage Plans Coventry / MoDot/MSHP Coventry / University of Missouri Claims Coventry Health Care Coventry One Cox Health Systems CRA Managed Care, Inc. Dakotas & Western Benefits Admin Davis Vision Definity Health Disability Determinations Division of Family Services EFCO Corporation Epoch Group,LC Equicor, Inc. Equitable Life & Casualty Equitable Plan Services Esis Essence Healthcare Evercare Everence Everest Eyeconic EyeMed EyeQuest Family Support Division Farmers Insurance Exchange Federated Mutual Insurance Co. First Choice Administrators First Continental Life & Accident Insurance Co. First Health First Health (Federated) First Health Network / Starmark First Health Part D / Medico First Steps Fiser V Health Floricda Medicaid FMH Benefit Services FMH/Heath Link Foreign Mission Board Fortis Benefits Fortis Benefits Ins Co. Fortis Benefits Insurance Co. Freedom Blue PPO Freedom Network Select GE Medicare Benefit Plans GEHA General American Life General American Life General Casualty Golden Rule Ins Co Gov't Employees Health Assc GPM Life Great West (Cheyenne,WY) Great West (Kennett, MO) Greene County Children's Division Grinnell Mutual Reinsurance Co. Group Health Plan Guarantee Trust Life Ins. Company Guardian GWH- Cigna Harden & Company Harrington Southwest HCH Administrators health Health Insurance Innovations Co-Ord Ben Plans Health Link Open Access Health Link/Freedom (PO Box 419104) Health Link/HSB HealthCare Solutions Group HealthChoice HealthFlex Healthlink/ Christian Brothers HealthScope HealthSmart Benefit Solutions Healthsmart Preferred Care, Inc. Healthy Alliance Life Ins. Co. Highmark / Freedom Blue PPO Hillcrest Benefit Administrator HIP Home State Health Care (MCD) HSI Benefit Systems Humana Choice PPO Humana Claims Humana Connect Medicare Supplement Humana Gold Choice Humana Gold Plus HMO (Box 14601, Lexington KY) Humana Insurance Co. Humana Medicare PPO Humana, Inc. IAC IMG Indiana Laboreres Welfare Fund Insurance Admin Solutions Insurance Managemant Admin John Alden Life Insurance Co. Laborers Health & Welfare LaHood and Associates Life Investors Insurance Lions Club Mail Handlers Benefit Plan Manhattan Life Ins Marathon Electric Marquette National Mass Mutual Mattax-Neu-Prater Med Benefit Systems Med Pay Med Plans 2000 Medco Medica Medical-Cigna Healthcare Medical Review Team Medicare Supplement Operations Medico Medifit Insurance Medishare Medivest Meeks Building-Med Pay Mercer Mercy Benefits Administrators Mercy Medicare Advantage HMO-POS Mercy Medicare Advantage (PPO) Meritain Health ( Minneapolis, MN) Meritain Health (Richardson, TX) Metropolitan Life Insurance Missouri Employee Mutual Ins Missouri Employers Mutual Missouri Eye Institute Missouri Healthnet Missouri Valley Mo-Kan Sheet Metal Workers Welfare Fund MO Care Health Plan(MCD) MoDOT/MSHP Claims Molina Healthcare Monumental Life Mosers/Humana MSC MSTA Claims Unit Municipal Health Benefit Fund Mutual Assurance Adninistrators Mutual of Omaha National Automatic Sprinkler Industry National Travelers Life Nationwide Specialty Health Claims NEI New Era Life Insurance Company New Insurance NHP Group Limited Benefit Claims Nordian Administrative Services North American Ins. Co. NVA Oklahoma State & Education Employees Old Surety Life Ins Comp Omaha Insurance Company OptumHealth Vision Claims Dept Oxford Life Ins Ozark Health Plan Painters District Council #2 Welfare Plan Paradigm Mangement Serives, LLC Pension Associates PHCS Physicians Mutual Pioneer Life Preferred Health Professionals Premier Plus HMO Premier Plus Options Prevention of Blindness Principal (Clearwater, FL) Principal Financial Group Principal Health Care, Inc. Principal Life Ins Dental/Vision Principal LIfe Insurance Co. (Colorado Springs) Principal Mutual Group Principal Mutual Insurance Co. Principal Mutual Life Principle Health Care, Inc-PPO Professional Benefit Admin. Provident Insurance Co. Provident Life and Accident Provident Life and Accident Prudential Custom Care Pyramid Claims QBE Qual Choice RCBA/Healthlink Rehab Services F/T Blind Reserve National Insurance Co. Restat Roebuck Administrators, Inc. Royal Neighbors of America Seabright Insurance Secure Horizons Security Life InsuranceCo. Sheet Metals Workers Local 104 Spectera St Johns Claims Admin Standard Life & Accident Ins Starmark State Farm Health Insurance State Mutual Life Assurance Sterling Investors Life Ins Comp Stonebridge Life Superior Vision TCS Team Care The Federated Insurance Co. The Guardian Insurance Co. The Hartford The Principal Financial Group The Principal Financial Group The Principal Mutual Group The Travelers-P-C Claim Dept The Travelers Consolidated The Travelers Insurance Co. Thrivent Financial for Lutherans TIC International Corp Time Ins Co Time Insurance Co. Today's Options / Pyramid Life Trans American Life Traveler's (Work Comp) Travelers Insurance Tricare For Life Tricare West Region Claims TriWest Healthcare Alliance UFCW Food Trades & Indust. Health & Welfare UGS- Global Care, Inc. UMR UMR Unicare Union Bankers United American Insurance Company United Health Care United Health Care (El Paso, TX) United Health Care Community Plan United Health Care Dual Complete / Sr Medicare Adv United Healthcare (Atlanta) United Healthcare (Salt Lake)(PO Box 30555) UNITED HEALTHCARE / CARE IMPROVEMENT United Healthcare / Medicare Solutions/Medicare Advantage United Healthcare Medicare Direct United Healthcare Midwest (MCD) UNITED HEALTHCARE SHARED SERVICES United Healthcare Vision United Teacher Assc.(Austin, TX) United World LIfe Ins USA MCO H&W Network USAA Life Insurance Company USAble Life Group Health Veterans Administration / VISN 16 Consolidated Fee Unit Vision USA VisionUSA Vocational Rehabilitation VSP VSP/ ASPEX FRAME CLAIMS Wakely & Associates, Inc. Washington National (Lincolnshire, IL) Washington National (Phoenix, AZ) Washington National Insurance Company (Carmel, IN) Wausau Insurance Co. Wellcare Concert PFFS Plan WellCare PFFS Western Teamsters Welfare Trust Westport Benefits(St.Loius) Worldwide Insurance WPS Medicare Part B Zurich North America
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:

ADULT History

If you are new to our office, please share with us how you found us.
Another patient Insurance List/ Insurance Website Internet Kids Directory Radio YP (Yellow Pages) Other

Do you...? (Check all that apply)
wear prescription glasses?
wear contact lenses? If so, what kind? Solution used:
experience discomfort with your contacts?
use over-the-counter eye drops?
use reading glasses?
work at a computer? If so, approximately how many hours a day?

Are you interested in getting a contact lens evaluation today? (Additional fees apply) Yes No

What is your occupation?

What are your hobbies?


What specific problems do you have with your vision, eyes, glasses, or contact lenses that you would like to discuss with the doctor today?


PATIENT EYE HISTORY

Date of Last Eye Exam: Previous Eye Doctor:

In the past 6 months, have you experienced any of the following? (Please check all that apply)
Blurry Vision
Eye turn
Double Vision
Flashes of light
Floaters/seeing spots
Eye Injury/Trauma
Eye Fatigue
Sensitivity to light
Red eyes
Itching/burning eyes
Dry Eye
Watery eyes

Other eye problems/issues:


Do you have a family history of any of the following? (Please check all that apply and list which family member, including maternal or paternal side of the family, if known)

Blindness
Eye Disease
Glaucoma
Macular Degeneration
Stroke
Strabismus/Eye Turn
Diabetes
Thyroid Condition
Heart Disease
Autoimmune Disease

PATIENT MEDICAL HISTORY

Primary Physician: Pharmacy:

CURRENT MEDICATIONS (Please list ALL medications including eye drops and supplements)


Please list any ALLERGIES to medications.


Please list any surgeries, including eye surgeries.


REVIEW OF SYSTEMS: Please check the box beside any condition you currently have, or have had in the following areas:

CONSTITUTIONAL: Fatigue Weight gain Weight Loss

EARS, NOSE, MOUTH & THROAT: Hearing Loss Sinus Infection/Problems Dry Mouth/Throat

CARDIOVASCULAR: High Blood Pressure High Cholesterol Heart Disease/Heart Attack Congestive Heart Failure

RESPIRATORY: Asthma COPD Emphysema Chronic Cough

GENITOURINARY: Bladder or Kidney Problems Ovarian/Uterine Cancer Prostate Cancer

GASTROINTESTINAL: IBS Acid Reflux Ulcers

MUSCULOSKELETAL: Arthritis Joint Pain Muscle Pain

INTEGUMENTARY (SKIN): Cancer Eczema Rashes

ENDOCRINE:Type 1 Diabetes Type 2 Diabetes Hyperthyroid Hypothyroid

NEUROLOGICAL: Headaches/Migraines Seizures Stroke Alzheimer's

HEMATOLOGIC / LYMPHATIC: Anemia Breast Cancer Bleeding/Clotting Problems

PSYCHIATRIC: Depression Anxiety Mood disorder

ALLERGIC / IMMUNOLOGIC: Seasonal Allergies

If you checked any of the boxes above or have a condition not listed, please explain further:


Are you pregnant or nursing? Yes No If pregnant, how many weeks?

Are you a smoker? Yes No Former
Do you drink alcohol? Yes No If yes, how often/much:
Do you use other substances? Yes No If yes, what type/how often/amount:

OPTIONAL Demographic Information: (This information if obtained for reporting purposes only)

Race: American Indian or Alaska Native Asian Black or African American White Other Race Ethnicity: Not Hispanic or Latino Hispanic or Latino Unknown

Remember to go to the final SUBMIT tab to send your forms. Thank You!

CHILD History

If you are new to our office, please share with us how you found us. Another patient Insurance List/ Insurance Website Internet Kids Directory Radio YP (Yellow Pages) Other

Is this your child by: Birth Adoption Step Child
Other

Parent(s) Name(s): Parent SSN:
Parent(s) Occupation(s):

Child's Grade Level: School:

Does your child...? (Check all that apply)
wear prescription glasses?
wear contact lenses? If so, what kind? Solution used:
experience discomfort with contacts?
have a rapidly increasing prescription?
participate in sports?

Are you considering contact lenses for your child? (Additional fees apply) Yes No

What specific concerns regarding your child's vision would you like to discuss with the doctor today?


How long has this problem/difficulty been observed?

PATIENT EYE HISTORY

Date of Last Eye Exam: Previous Eye Doctor:

In the past 6 months, has your child experienced any of the following? (Please check all that apply)

Blurry Vision	Amblyopia/"Lazy Eye"
Double Vision	Eye turn
Headaches	Eye Injury/Trauma
Sensitivity to light	Red eyes
Eye Fatigue	Dry Eye
Itching/burning eyes	Color Blindness
Difficulty Reading	Reversals

Other eye problems/issues:

Do you have a family history of any of the following? (Please check all that apply)

Blindness	Eye Disease
Glaucoma	Heart Disease
Macular Degeneration	Brain Tumor
Diabetes	Strabismus/Eye Turn
Thyroid Condition	Learning Disability
Epilepsy/Seizures	Autoimmune Disease

PATIENT MEDICAL HISTORY

Primary Physician:

CURRENT MEDICATIONS (Please list ALL medications including eye drops and supplements)


Please list any ALLERGIES to medications (including topical medications):


Premature birth? No Yes Any complications during pregnancy? No Yes
If yes, please describe:


Shown normal development? Yes No Had physical/developmental therapy? Yes No

Please list any surgeries, including eye surgeries.


Please list serious illnesses, bad falls, etc.:


Has your child ever been diagnosed or treated for any of the following health conditions? (Please check all that apply)

Type 1 Diabetes	Seizures	Depression
Type 2 Diabetes	Stroke	Anxiety
Hyperthyroid	Asthma	Mood disorder
Hypothyroid	Headaches/Migraines	Autoimmune Disorder
Skin lesions/rashes/eczema	Seasonal allergies	Cancer

If your child has any other health conditions not listed above, please include those here:


EDUCATION HISTORY

Does your child use an Ipad/tablet in the classroom? Yes No Unsure

How much screen time does your child get per day?

Does your child have a 504 plan or I.E.P. at school? Yes No

Has your child had extra help or tutoring in school? Yes No

Has a grade been repeated? Yes No If so, which?

How would you describe your child's reading ability?
Does he/she like to read for fun? Yes No

School/after-school activities your child is involved in:

Do you feel your child is achieving up to potential?

OPTIONAL Demographic Information: (This information if obtained for reporting purposes only)

Race: American Indian or Alaska Native Asian Black or African American White Other Race Ethnicity: Not Hispanic or Latino Hispanic or Latino Unknown

If your child is scheduled for our DEVELOPMENTAL EVALUATION, please continue to the next section, if not remember to go to the final SUBMIT tab to send your forms. Thank You!

DEVELOPMENTAL EVALUATION QUESTIONNAIRE

Symptom Checklist
Has your child or anyone observing your child ever noticed the following? (Please check all that apply)

Headaches following reading/computer work	Reverses letters, numbers or words
Eyes hurt after close work	Difficulty tracking moving objects
Feel unusually tired after completing a task	Squints, closes, or covers an eye
Unusual blinking	Unusual posture/head tilt with near work
Unusual eye rubbing	Avoids near tasks
Dry eyes	Loses awareness of surroundings when concentrating
Watery eyes	Motion/car sickness
Blurry at distance when looking up from near	Complete this section only if your child is a reader:
Print seems to move or go in and out of focus	Skips words while reading/copying
Crooked and/or poorly spaced handwriting	Loses place while reading/copying
Misaligns letters and/or numbers	Skips lines while reading/copying
Makes errors when copying	Rereads words or lines
Poor spelling skills	Poor reading comprehension
Dislikes tasks requiring sustained concentration	Holds head too close when reading/writing
Confuses right and left directions	Letters/lines "run together" or "jump"
Restlessness when working at a desk (2491)	Feels sleepy when reading
Poor concentration abilities	Uses finger as a marker when reading
Unusual clumsiness	Reads slowly
Difficulty with eye-hand coordination	Vocalizes when reading silently
Short attention span/loses interest	Difficulty recognizing the same word on a different page

Has an IEP or similar school evaluation been performed? No Yes Unsure Were accommodations recommended? No Yes Unsure
If yes, please describe the program and results:

Has a speech or language evaluation been performed? No Yes Unsure Was speech therapy recommended? No Yes Unsure
If yes, please describe the patient age and results:

Has an occupational therapy evaluation been performed? No Yes Unsure Was occupational therapy recommended? No Yes Unsure
If yes, please describe the patient age and results:

Has a neurological or psychological evaluation been performed? No Yes Unsure By whom?
Please describe the results and recommendations:

Has a vision therapy evaluation been performed? No Yes Unsure By whom? Was vision therapy recommended? No Yes Unsure
If yes, please describe the program and results:

FAMILY AND HOME
Please indicate which adult(s) he/she lives with: Mother Father Stepmother Stepfather Grandmother Grandfather
Other Caretaker

Are there other children at home?

Has your child ever been through a traumatic family situation (such as divorce, parental loss, severe parental illness, separation)? No Yes
If yes, at what age? Does your child seem to have adjusted? Yes No Is family life stable at this time? Yes No
If no, please explain:


Please give a brief description of your child as a person and add any additional information you feel would be helpful in our treatment of your child.


Remember to go to the final SUBMIT tab to send your forms. Thank You!

Submit Data