Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
MR. MRS. MS. DR.

Address:
City:		State/ZipCode	LA MS AR TX AL OK

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

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
MR. MRS. MS. DR.

Address

City	State	ZipCode
	LA MS AR TX AL OK

Home Phone:
Work Phone:

Vision Insurance

Primary Vision Insurance Information

Insurance Name:	None AARP AETNA AETNA MCR SUPPLEMENT AETNA MEDICARE AFLAC AIG, HIGHER EDUCATION MAIL CENTER ALL SAVERS ALL STATE ALLEGIANCE BENEFIT PLAN MANAG ALLIED BENEFIT SYSTEM ALWAYS CARE BENEFITS, INC AMERI BEN AMERICAN HERITAGE LIFE INS CO AMERITAS APWU-CIGNA APWU-UHC ASR HEALTH BENEFITS ASSOCIATION & SOCIETY INSURANCE CORP ASSURANT HEALTH ASSURED LIFE ASSCOCIATION BANKERS LIFE AND CASUALTY CO BAS, LTD. BC LIFE & HEALTH INSURANCE CO. BEECH STREET BENEFIT MANAGEMENT BENEFIT PLANNERS BENESYS Bestcare Blue Cross Blue Shield of LA BMA BOON-CHAPMAN CAPITOL ADMINISTRATORS CBA CBCA CBSA CCMSI CDS GROUP HEALTH CECHP CELTIC CHAMP VA CHESTERFIELD RESOURCES INC CHRISTIAN BROTHERS CIGNA CIGNA VA CIGNA/GREAT WEST CINERGY HEALTH CLAIMEDIX, INC COLONIAL MEDICAL INSURANCE COLONIAL PENN LIFE INS CO COMMERCE BENEFITS GROUP COMMUNITY CARE COMPREHENSIVE CARE SERVICES CONTINENTAL GENERAL CONTINENTAL LIFE COOPERATIVE BENEFIT ADMIN CORPORATE BEN SRVCS OF AMERICA COVENANT ADMINISTRATORS, INC. COVENTRY HEALTH CARE OF LA INC CRAWFORD & COMPANY CSI MEDICARE SUP DEFINITY HEALTH DISTRICT ATTORNEY'S OFFICE DIVERSIFIED ADMINISTRATION COR DOMINION VISION PLAN DUNN & ASSOCIATES EBMS EMPLOYEE BENEFIT SERVICES OF A ENTRUST FIRST HEALTH EQUITABLE LIFE EUROPEAN BENEFITS Eyemed Vision Plan/ECPA FARA FCE BENEFITS FEDERAL DISABILITY DETERMINATN First Health FISERV HEALTH FMH BENEFIT SERVICES FORTIS INS COMPANY FREEDOM LIFE INS CO OF AMERICA FUGRO, INC GALLAGHER BASSETT SERVICES GEHA GHC-SCW GHI GILSBAR, INC GOLDEN RULE INSURANCE COM. GOV. EMP. HOSPITAL ASSOC. GPA GRI GROUP & PENSION ADMINISTRATORS GROUP ADMINISTRATION SERVICES GROUP RESOURCES INCORPORATED GUARANTY ASSURANCE COMPANY GULF SOUTH RISK SERVICES INC HARRINGTON HEALTH HBPA HEALTH ADVANTAGE HEALTH ALLIANCE HEALTH CHOICE HEALTH COMP HEALTH COST SOLUTIONS HEALTH DESIGN PLUS HEALTH FIRST HEALTH SPRINGS HEALTHPARTNERS CLAIMS HEALTHSCOPE BENEFITS HEALTHSMART BENEFIT SOLUTIONS HEARTLAND NATIONAL HOMELAND HEALTH CARE HUMANA HUMANA VISION IAC INSURANCE CENTER INSURANCE MANAGEMENT ADM INSURANCE MANAGEMENT SERVICES INTERNATIONAL BENEFITS ADMINISTRATORS J.P. FARLEY JEFFERSON LIFE INS CO JESUIT HEALTH TRUS LA CARPENTERS REG COUNCIL LA HEALTH CARE SELF INS CO LA STATE DISABILITY LA WORKERS COMPENSATION LAFAYETTE GENERAL HOSPITAL LHS.MED COST LIFERE INSURANCE COMPANY LINCOLN HERITAGE LOCAL-25 LOUISIANA HEALTH COOPERATIVE LOUISIANA HORSEMEN'S MEDICAL BENEFIT TRUST LOUSIANA SOCIAL SERVICES LOYAL AMERICAN LUMENOS MACORI ADMINISTRATION MAIL HANDLERS BENEFIT PLAN MALEY, COMEAUX & FALTERMAN MANHATTAN LIFE MARATHON MARATHONA INS MARINE CORPS ASSO MARQUETTE LIFE MARSH AFFINITY GROUP MEAUX SURFACE PROTECTION MED MUTUAL MEDCO HEALTH SOLUTIONS, INC. MEDI-SHARE MEDICA MEDICAID Medicare MEDICO INS COMPANY MEDIPLUS MEGA LIFE MERITAIN MERITAIN HEALTH METLIFE VISION METLIFE VISION MHEALTH MHHEALTH PLAN MHHNP MID-WEST NATIONAL LIFE MIDWEST LIFE MONUMENTAL LIFE MULTIPLAN MUTUAL OF OMAHA NAT'L ELEVATOR INDUS HEALTH BP NATION ASSOC OF LETTER CARRIER NATIONAL FOUNDATION LIFE NATIONAL STATES INS CO NATIONAL TELECOMMUNICATIONS CO NATIONAL VISION ADMINISTRATORS NATIONWIDE SPECIALTY HEALTH NCAS NEW ERA LIFE INS New Insurance NHBC-HEWITT NORTH AMERICAN BENEFITS NETWOK NORTHEAST OHIO EYE SURGEONS NOVA HEALTHCARE ADM, INC ODS OLD SURETY LIFE INS COMPANY OLYMPIC HEALTH ONESOURCE ADMINISTRATORS OPTIMA HEALTH OREGON PUBLIC EMPLOYEES OSCHNER HEALTH PLAN OXFORD HEALTH PACIFICARE LIFE AND HEALTH PAI PAN-AMERICAN LIFE INSURANCE CO PEACE CORPS HEALTH BENEFIT PROGRTAM PENNSYLVANIA LIFE PEOPLES HEALTH PERRIER AND LACOSTE PHILADELPHIA AMERICA LIFE INS PHYSICIANS LIFE PHYSICIANS MUTUAL INSURANCE CO PINNACLE HEALTH CLAIMS MANAGEMENT PIPELINE INDUSTRY BEN. FUND PPO PLUS, LLC PPOM PREFERRED BENEFIT ADMIN PREFERRED HEALTH SYSTEMS PRIMARY PHYSICIAN CARE PRINCIPAL FINANCIAL GROUP PRIORITY 1 PRUDENTIAL LIFE PYRAMID CLAIMS PYRAMID LIFE RABALAIS, HANNA & HEBERT RAIL ROAD MEDICARE REHABCARE OF LA RELIANCE STANDARD LIFE INS CO RISK MANAGEMENT SERVICES ROYAL EMBESSY OF SAUDI ARABIA RURAL CARRIER SAFEGUARD SCHLUMBERGER INTERNATIONAL SEAFARERS SECURE HORIZONS SECURITY LIFE SELF INSURED SERVICES COMPNAY SENTINEL LIFE SHEET METAL WORKERS FUND SHELTER LIFE INSURANCE COMPANY SIERRA HEALTH AND LIFE SOCIETY OF THE DIVINE WORLD SOUTHERN BENEFIT SERVICES LLC SOUTHERN FIRE PROTECTION STANDARD LIFE STARMARK STATE FARM MUTUAL INSURANCE STERLING OPTION 1 STERLING OPTION II STERLING OPTION III STUDENT ASSURANCE SERVICES SUMMIT CLAIMS Superior Vision Plan TENET CHOICES 65 TEXAS IMPERIAL THE MEGA LIFE & HEALTH INS CO TIME INSURANCE TODAY'S OPTIONS TOTAL PLAN SERVICES INC TOWER LIFE INSURANCE COMPANY TRANSAMERICA LIFE TRANSAMERICA LIFE TRICARE SOUTH REGION TRUE CHOICE USA TRUSTMARK INSURANCE COMPANY UHC-SHARED SERVICES UHC MEDICARE SOLUTIONS UMR UMR--FRANCISCAN MISSIONARIES UNICARE UNIFORM MEDICAL PLAN UNITED AMERICAN UNITED CLAIM SOLUTIONS UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED HEALTHCARE UNITED HEALTHCARE INTERGRATED SERVICES UNITED MEDICAL RESOURCES UNITED TEACHER ASSOCIATES UNITED WORLD LIFE INS CO UNIVERA HEALTHCARE UNIVERSAL HEALTH CARE, INC. USAA LIFE INS CO. VANTAGE HEALTH PLAN, INC VERITY VSP WAUSAU BENEFITS WEB-TPA WELLCARE WELLS FARGO TPA WESTERN& SOUTHERN WINDSOR STERLING WOODMEN OF THE WORLD WORKERS COMP WORLD INSURANCE WPS-VA
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 Vision Insurance Information

Insurance Name:	None AARP AETNA AETNA MCR SUPPLEMENT AETNA MEDICARE AFLAC AIG, HIGHER EDUCATION MAIL CENTER ALL SAVERS ALL STATE ALLEGIANCE BENEFIT PLAN MANAG ALLIED BENEFIT SYSTEM ALWAYS CARE BENEFITS, INC AMERI BEN AMERICAN HERITAGE LIFE INS CO AMERITAS APWU-CIGNA APWU-UHC ASR HEALTH BENEFITS ASSOCIATION & SOCIETY INSURANCE CORP ASSURANT HEALTH ASSURED LIFE ASSCOCIATION BANKERS LIFE AND CASUALTY CO BAS, LTD. BC LIFE & HEALTH INSURANCE CO. BEECH STREET BENEFIT MANAGEMENT BENEFIT PLANNERS BENESYS Bestcare Blue Cross Blue Shield of LA BMA BOON-CHAPMAN CAPITOL ADMINISTRATORS CBA CBCA CBSA CCMSI CDS GROUP HEALTH CECHP CELTIC CHAMP VA CHESTERFIELD RESOURCES INC CHRISTIAN BROTHERS CIGNA CIGNA VA CIGNA/GREAT WEST CINERGY HEALTH CLAIMEDIX, INC COLONIAL MEDICAL INSURANCE COLONIAL PENN LIFE INS CO COMMERCE BENEFITS GROUP COMMUNITY CARE COMPREHENSIVE CARE SERVICES CONTINENTAL GENERAL CONTINENTAL LIFE COOPERATIVE BENEFIT ADMIN CORPORATE BEN SRVCS OF AMERICA COVENANT ADMINISTRATORS, INC. COVENTRY HEALTH CARE OF LA INC CRAWFORD & COMPANY CSI MEDICARE SUP DEFINITY HEALTH DISTRICT ATTORNEY'S OFFICE DIVERSIFIED ADMINISTRATION COR DOMINION VISION PLAN DUNN & ASSOCIATES EBMS EMPLOYEE BENEFIT SERVICES OF A ENTRUST FIRST HEALTH EQUITABLE LIFE EUROPEAN BENEFITS Eyemed Vision Plan/ECPA FARA FCE BENEFITS FEDERAL DISABILITY DETERMINATN First Health FISERV HEALTH FMH BENEFIT SERVICES FORTIS INS COMPANY FREEDOM LIFE INS CO OF AMERICA FUGRO, INC GALLAGHER BASSETT SERVICES GEHA GHC-SCW GHI GILSBAR, INC GOLDEN RULE INSURANCE COM. GOV. EMP. HOSPITAL ASSOC. GPA GRI GROUP & PENSION ADMINISTRATORS GROUP ADMINISTRATION SERVICES GROUP RESOURCES INCORPORATED GUARANTY ASSURANCE COMPANY GULF SOUTH RISK SERVICES INC HARRINGTON HEALTH HBPA HEALTH ADVANTAGE HEALTH ALLIANCE HEALTH CHOICE HEALTH COMP HEALTH COST SOLUTIONS HEALTH DESIGN PLUS HEALTH FIRST HEALTH SPRINGS HEALTHPARTNERS CLAIMS HEALTHSCOPE BENEFITS HEALTHSMART BENEFIT SOLUTIONS HEARTLAND NATIONAL HOMELAND HEALTH CARE HUMANA HUMANA VISION IAC INSURANCE CENTER INSURANCE MANAGEMENT ADM INSURANCE MANAGEMENT SERVICES INTERNATIONAL BENEFITS ADMINISTRATORS J.P. FARLEY JEFFERSON LIFE INS CO JESUIT HEALTH TRUS LA CARPENTERS REG COUNCIL LA HEALTH CARE SELF INS CO LA STATE DISABILITY LA WORKERS COMPENSATION LAFAYETTE GENERAL HOSPITAL LHS.MED COST LIFERE INSURANCE COMPANY LINCOLN HERITAGE LOCAL-25 LOUISIANA HEALTH COOPERATIVE LOUISIANA HORSEMEN'S MEDICAL BENEFIT TRUST LOUSIANA SOCIAL SERVICES LOYAL AMERICAN LUMENOS MACORI ADMINISTRATION MAIL HANDLERS BENEFIT PLAN MALEY, COMEAUX & FALTERMAN MANHATTAN LIFE MARATHON MARATHONA INS MARINE CORPS ASSO MARQUETTE LIFE MARSH AFFINITY GROUP MEAUX SURFACE PROTECTION MED MUTUAL MEDCO HEALTH SOLUTIONS, INC. MEDI-SHARE MEDICA MEDICAID Medicare MEDICO INS COMPANY MEDIPLUS MEGA LIFE MERITAIN MERITAIN HEALTH METLIFE VISION METLIFE VISION MHEALTH MHHEALTH PLAN MHHNP MID-WEST NATIONAL LIFE MIDWEST LIFE MONUMENTAL LIFE MULTIPLAN MUTUAL OF OMAHA NAT'L ELEVATOR INDUS HEALTH BP NATION ASSOC OF LETTER CARRIER NATIONAL FOUNDATION LIFE NATIONAL STATES INS CO NATIONAL TELECOMMUNICATIONS CO NATIONAL VISION ADMINISTRATORS NATIONWIDE SPECIALTY HEALTH NCAS NEW ERA LIFE INS New Insurance NHBC-HEWITT NORTH AMERICAN BENEFITS NETWOK NORTHEAST OHIO EYE SURGEONS NOVA HEALTHCARE ADM, INC ODS OLD SURETY LIFE INS COMPANY OLYMPIC HEALTH ONESOURCE ADMINISTRATORS OPTIMA HEALTH OREGON PUBLIC EMPLOYEES OSCHNER HEALTH PLAN OXFORD HEALTH PACIFICARE LIFE AND HEALTH PAI PAN-AMERICAN LIFE INSURANCE CO PEACE CORPS HEALTH BENEFIT PROGRTAM PENNSYLVANIA LIFE PEOPLES HEALTH PERRIER AND LACOSTE PHILADELPHIA AMERICA LIFE INS PHYSICIANS LIFE PHYSICIANS MUTUAL INSURANCE CO PINNACLE HEALTH CLAIMS MANAGEMENT PIPELINE INDUSTRY BEN. FUND PPO PLUS, LLC PPOM PREFERRED BENEFIT ADMIN PREFERRED HEALTH SYSTEMS PRIMARY PHYSICIAN CARE PRINCIPAL FINANCIAL GROUP PRIORITY 1 PRUDENTIAL LIFE PYRAMID CLAIMS PYRAMID LIFE RABALAIS, HANNA & HEBERT RAIL ROAD MEDICARE REHABCARE OF LA RELIANCE STANDARD LIFE INS CO RISK MANAGEMENT SERVICES ROYAL EMBESSY OF SAUDI ARABIA RURAL CARRIER SAFEGUARD SCHLUMBERGER INTERNATIONAL SEAFARERS SECURE HORIZONS SECURITY LIFE SELF INSURED SERVICES COMPNAY SENTINEL LIFE SHEET METAL WORKERS FUND SHELTER LIFE INSURANCE COMPANY SIERRA HEALTH AND LIFE SOCIETY OF THE DIVINE WORLD SOUTHERN BENEFIT SERVICES LLC SOUTHERN FIRE PROTECTION STANDARD LIFE STARMARK STATE FARM MUTUAL INSURANCE STERLING OPTION 1 STERLING OPTION II STERLING OPTION III STUDENT ASSURANCE SERVICES SUMMIT CLAIMS Superior Vision Plan TENET CHOICES 65 TEXAS IMPERIAL THE MEGA LIFE & HEALTH INS CO TIME INSURANCE TODAY'S OPTIONS TOTAL PLAN SERVICES INC TOWER LIFE INSURANCE COMPANY TRANSAMERICA LIFE TRANSAMERICA LIFE TRICARE SOUTH REGION TRUE CHOICE USA TRUSTMARK INSURANCE COMPANY UHC-SHARED SERVICES UHC MEDICARE SOLUTIONS UMR UMR--FRANCISCAN MISSIONARIES UNICARE UNIFORM MEDICAL PLAN UNITED AMERICAN UNITED CLAIM SOLUTIONS UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED HEALTHCARE UNITED HEALTHCARE INTERGRATED SERVICES UNITED MEDICAL RESOURCES UNITED TEACHER ASSOCIATES UNITED WORLD LIFE INS CO UNIVERA HEALTHCARE UNIVERSAL HEALTH CARE, INC. USAA LIFE INS CO. VANTAGE HEALTH PLAN, INC VERITY VSP WAUSAU BENEFITS WEB-TPA WELLCARE WELLS FARGO TPA WESTERN& SOUTHERN WINDSOR STERLING WOODMEN OF THE WORLD WORKERS COMP WORLD INSURANCE WPS-VA
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 Insurance

Primary Medical Insurance Information

Insurance Name:	None AARP AETNA AETNA MCR SUPPLEMENT AETNA MEDICARE AFLAC AIG, HIGHER EDUCATION MAIL CENTER ALL SAVERS ALL STATE ALLEGIANCE BENEFIT PLAN MANAG ALLIED BENEFIT SYSTEM ALWAYS CARE BENEFITS, INC AMERI BEN AMERICAN HERITAGE LIFE INS CO AMERITAS APWU-CIGNA APWU-UHC ASR HEALTH BENEFITS ASSOCIATION & SOCIETY INSURANCE CORP ASSURANT HEALTH ASSURED LIFE ASSCOCIATION BANKERS LIFE AND CASUALTY CO BAS, LTD. BC LIFE & HEALTH INSURANCE CO. BEECH STREET BENEFIT MANAGEMENT BENEFIT PLANNERS BENESYS Bestcare Blue Cross Blue Shield of LA BMA BOON-CHAPMAN CAPITOL ADMINISTRATORS CBA CBCA CBSA CCMSI CDS GROUP HEALTH CECHP CELTIC CHAMP VA CHESTERFIELD RESOURCES INC CHRISTIAN BROTHERS CIGNA CIGNA VA CIGNA/GREAT WEST CINERGY HEALTH CLAIMEDIX, INC COLONIAL MEDICAL INSURANCE COLONIAL PENN LIFE INS CO COMMERCE BENEFITS GROUP COMMUNITY CARE COMPREHENSIVE CARE SERVICES CONTINENTAL GENERAL CONTINENTAL LIFE COOPERATIVE BENEFIT ADMIN CORPORATE BEN SRVCS OF AMERICA COVENANT ADMINISTRATORS, INC. COVENTRY HEALTH CARE OF LA INC CRAWFORD & COMPANY CSI MEDICARE SUP DEFINITY HEALTH DISTRICT ATTORNEY'S OFFICE DIVERSIFIED ADMINISTRATION COR DOMINION VISION PLAN DUNN & ASSOCIATES EBMS EMPLOYEE BENEFIT SERVICES OF A ENTRUST FIRST HEALTH EQUITABLE LIFE EUROPEAN BENEFITS Eyemed Vision Plan/ECPA FARA FCE BENEFITS FEDERAL DISABILITY DETERMINATN First Health FISERV HEALTH FMH BENEFIT SERVICES FORTIS INS COMPANY FREEDOM LIFE INS CO OF AMERICA FUGRO, INC GALLAGHER BASSETT SERVICES GEHA GHC-SCW GHI GILSBAR, INC GOLDEN RULE INSURANCE COM. GOV. EMP. HOSPITAL ASSOC. GPA GRI GROUP & PENSION ADMINISTRATORS GROUP ADMINISTRATION SERVICES GROUP RESOURCES INCORPORATED GUARANTY ASSURANCE COMPANY GULF SOUTH RISK SERVICES INC HARRINGTON HEALTH HBPA HEALTH ADVANTAGE HEALTH ALLIANCE HEALTH CHOICE HEALTH COMP HEALTH COST SOLUTIONS HEALTH DESIGN PLUS HEALTH FIRST HEALTH SPRINGS HEALTHPARTNERS CLAIMS HEALTHSCOPE BENEFITS HEALTHSMART BENEFIT SOLUTIONS HEARTLAND NATIONAL HOMELAND HEALTH CARE HUMANA HUMANA VISION IAC INSURANCE CENTER INSURANCE MANAGEMENT ADM INSURANCE MANAGEMENT SERVICES INTERNATIONAL BENEFITS ADMINISTRATORS J.P. FARLEY JEFFERSON LIFE INS CO JESUIT HEALTH TRUS LA CARPENTERS REG COUNCIL LA HEALTH CARE SELF INS CO LA STATE DISABILITY LA WORKERS COMPENSATION LAFAYETTE GENERAL HOSPITAL LHS.MED COST LIFERE INSURANCE COMPANY LINCOLN HERITAGE LOCAL-25 LOUISIANA HEALTH COOPERATIVE LOUISIANA HORSEMEN'S MEDICAL BENEFIT TRUST LOUSIANA SOCIAL SERVICES LOYAL AMERICAN LUMENOS MACORI ADMINISTRATION MAIL HANDLERS BENEFIT PLAN MALEY, COMEAUX & FALTERMAN MANHATTAN LIFE MARATHON MARATHONA INS MARINE CORPS ASSO MARQUETTE LIFE MARSH AFFINITY GROUP MEAUX SURFACE PROTECTION MED MUTUAL MEDCO HEALTH SOLUTIONS, INC. MEDI-SHARE MEDICA MEDICAID Medicare MEDICO INS COMPANY MEDIPLUS MEGA LIFE MERITAIN MERITAIN HEALTH METLIFE VISION METLIFE VISION MHEALTH MHHEALTH PLAN MHHNP MID-WEST NATIONAL LIFE MIDWEST LIFE MONUMENTAL LIFE MULTIPLAN MUTUAL OF OMAHA NAT'L ELEVATOR INDUS HEALTH BP NATION ASSOC OF LETTER CARRIER NATIONAL FOUNDATION LIFE NATIONAL STATES INS CO NATIONAL TELECOMMUNICATIONS CO NATIONAL VISION ADMINISTRATORS NATIONWIDE SPECIALTY HEALTH NCAS NEW ERA LIFE INS New Insurance NHBC-HEWITT NORTH AMERICAN BENEFITS NETWOK NORTHEAST OHIO EYE SURGEONS NOVA HEALTHCARE ADM, INC ODS OLD SURETY LIFE INS COMPANY OLYMPIC HEALTH ONESOURCE ADMINISTRATORS OPTIMA HEALTH OREGON PUBLIC EMPLOYEES OSCHNER HEALTH PLAN OXFORD HEALTH PACIFICARE LIFE AND HEALTH PAI PAN-AMERICAN LIFE INSURANCE CO PEACE CORPS HEALTH BENEFIT PROGRTAM PENNSYLVANIA LIFE PEOPLES HEALTH PERRIER AND LACOSTE PHILADELPHIA AMERICA LIFE INS PHYSICIANS LIFE PHYSICIANS MUTUAL INSURANCE CO PINNACLE HEALTH CLAIMS MANAGEMENT PIPELINE INDUSTRY BEN. FUND PPO PLUS, LLC PPOM PREFERRED BENEFIT ADMIN PREFERRED HEALTH SYSTEMS PRIMARY PHYSICIAN CARE PRINCIPAL FINANCIAL GROUP PRIORITY 1 PRUDENTIAL LIFE PYRAMID CLAIMS PYRAMID LIFE RABALAIS, HANNA & HEBERT RAIL ROAD MEDICARE REHABCARE OF LA RELIANCE STANDARD LIFE INS CO RISK MANAGEMENT SERVICES ROYAL EMBESSY OF SAUDI ARABIA RURAL CARRIER SAFEGUARD SCHLUMBERGER INTERNATIONAL SEAFARERS SECURE HORIZONS SECURITY LIFE SELF INSURED SERVICES COMPNAY SENTINEL LIFE SHEET METAL WORKERS FUND SHELTER LIFE INSURANCE COMPANY SIERRA HEALTH AND LIFE SOCIETY OF THE DIVINE WORLD SOUTHERN BENEFIT SERVICES LLC SOUTHERN FIRE PROTECTION STANDARD LIFE STARMARK STATE FARM MUTUAL INSURANCE STERLING OPTION 1 STERLING OPTION II STERLING OPTION III STUDENT ASSURANCE SERVICES SUMMIT CLAIMS Superior Vision Plan TENET CHOICES 65 TEXAS IMPERIAL THE MEGA LIFE & HEALTH INS CO TIME INSURANCE TODAY'S OPTIONS TOTAL PLAN SERVICES INC TOWER LIFE INSURANCE COMPANY TRANSAMERICA LIFE TRANSAMERICA LIFE TRICARE SOUTH REGION TRUE CHOICE USA TRUSTMARK INSURANCE COMPANY UHC-SHARED SERVICES UHC MEDICARE SOLUTIONS UMR UMR--FRANCISCAN MISSIONARIES UNICARE UNIFORM MEDICAL PLAN UNITED AMERICAN UNITED CLAIM SOLUTIONS UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED HEALTHCARE UNITED HEALTHCARE INTERGRATED SERVICES UNITED MEDICAL RESOURCES UNITED TEACHER ASSOCIATES UNITED WORLD LIFE INS CO UNIVERA HEALTHCARE UNIVERSAL HEALTH CARE, INC. USAA LIFE INS CO. VANTAGE HEALTH PLAN, INC VERITY VSP WAUSAU BENEFITS WEB-TPA WELLCARE WELLS FARGO TPA WESTERN& SOUTHERN WINDSOR STERLING WOODMEN OF THE WORLD WORKERS COMP WORLD INSURANCE WPS-VA
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 Medical Insurance Information

Insurance Name:	None AARP AETNA AETNA MCR SUPPLEMENT AETNA MEDICARE AFLAC AIG, HIGHER EDUCATION MAIL CENTER ALL SAVERS ALL STATE ALLEGIANCE BENEFIT PLAN MANAG ALLIED BENEFIT SYSTEM ALWAYS CARE BENEFITS, INC AMERI BEN AMERICAN HERITAGE LIFE INS CO AMERITAS APWU-CIGNA APWU-UHC ASR HEALTH BENEFITS ASSOCIATION & SOCIETY INSURANCE CORP ASSURANT HEALTH ASSURED LIFE ASSCOCIATION BANKERS LIFE AND CASUALTY CO BAS, LTD. BC LIFE & HEALTH INSURANCE CO. BEECH STREET BENEFIT MANAGEMENT BENEFIT PLANNERS BENESYS Bestcare Blue Cross Blue Shield of LA BMA BOON-CHAPMAN CAPITOL ADMINISTRATORS CBA CBCA CBSA CCMSI CDS GROUP HEALTH CECHP CELTIC CHAMP VA CHESTERFIELD RESOURCES INC CHRISTIAN BROTHERS CIGNA CIGNA VA CIGNA/GREAT WEST CINERGY HEALTH CLAIMEDIX, INC COLONIAL MEDICAL INSURANCE COLONIAL PENN LIFE INS CO COMMERCE BENEFITS GROUP COMMUNITY CARE COMPREHENSIVE CARE SERVICES CONTINENTAL GENERAL CONTINENTAL LIFE COOPERATIVE BENEFIT ADMIN CORPORATE BEN SRVCS OF AMERICA COVENANT ADMINISTRATORS, INC. COVENTRY HEALTH CARE OF LA INC CRAWFORD & COMPANY CSI MEDICARE SUP DEFINITY HEALTH DISTRICT ATTORNEY'S OFFICE DIVERSIFIED ADMINISTRATION COR DOMINION VISION PLAN DUNN & ASSOCIATES EBMS EMPLOYEE BENEFIT SERVICES OF A ENTRUST FIRST HEALTH EQUITABLE LIFE EUROPEAN BENEFITS Eyemed Vision Plan/ECPA FARA FCE BENEFITS FEDERAL DISABILITY DETERMINATN First Health FISERV HEALTH FMH BENEFIT SERVICES FORTIS INS COMPANY FREEDOM LIFE INS CO OF AMERICA FUGRO, INC GALLAGHER BASSETT SERVICES GEHA GHC-SCW GHI GILSBAR, INC GOLDEN RULE INSURANCE COM. GOV. EMP. HOSPITAL ASSOC. GPA GRI GROUP & PENSION ADMINISTRATORS GROUP ADMINISTRATION SERVICES GROUP RESOURCES INCORPORATED GUARANTY ASSURANCE COMPANY GULF SOUTH RISK SERVICES INC HARRINGTON HEALTH HBPA HEALTH ADVANTAGE HEALTH ALLIANCE HEALTH CHOICE HEALTH COMP HEALTH COST SOLUTIONS HEALTH DESIGN PLUS HEALTH FIRST HEALTH SPRINGS HEALTHPARTNERS CLAIMS HEALTHSCOPE BENEFITS HEALTHSMART BENEFIT SOLUTIONS HEARTLAND NATIONAL HOMELAND HEALTH CARE HUMANA HUMANA VISION IAC INSURANCE CENTER INSURANCE MANAGEMENT ADM INSURANCE MANAGEMENT SERVICES INTERNATIONAL BENEFITS ADMINISTRATORS J.P. FARLEY JEFFERSON LIFE INS CO JESUIT HEALTH TRUS LA CARPENTERS REG COUNCIL LA HEALTH CARE SELF INS CO LA STATE DISABILITY LA WORKERS COMPENSATION LAFAYETTE GENERAL HOSPITAL LHS.MED COST LIFERE INSURANCE COMPANY LINCOLN HERITAGE LOCAL-25 LOUISIANA HEALTH COOPERATIVE LOUISIANA HORSEMEN'S MEDICAL BENEFIT TRUST LOUSIANA SOCIAL SERVICES LOYAL AMERICAN LUMENOS MACORI ADMINISTRATION MAIL HANDLERS BENEFIT PLAN MALEY, COMEAUX & FALTERMAN MANHATTAN LIFE MARATHON MARATHONA INS MARINE CORPS ASSO MARQUETTE LIFE MARSH AFFINITY GROUP MEAUX SURFACE PROTECTION MED MUTUAL MEDCO HEALTH SOLUTIONS, INC. MEDI-SHARE MEDICA MEDICAID Medicare MEDICO INS COMPANY MEDIPLUS MEGA LIFE MERITAIN MERITAIN HEALTH METLIFE VISION METLIFE VISION MHEALTH MHHEALTH PLAN MHHNP MID-WEST NATIONAL LIFE MIDWEST LIFE MONUMENTAL LIFE MULTIPLAN MUTUAL OF OMAHA NAT'L ELEVATOR INDUS HEALTH BP NATION ASSOC OF LETTER CARRIER NATIONAL FOUNDATION LIFE NATIONAL STATES INS CO NATIONAL TELECOMMUNICATIONS CO NATIONAL VISION ADMINISTRATORS NATIONWIDE SPECIALTY HEALTH NCAS NEW ERA LIFE INS New Insurance NHBC-HEWITT NORTH AMERICAN BENEFITS NETWOK NORTHEAST OHIO EYE SURGEONS NOVA HEALTHCARE ADM, INC ODS OLD SURETY LIFE INS COMPANY OLYMPIC HEALTH ONESOURCE ADMINISTRATORS OPTIMA HEALTH OREGON PUBLIC EMPLOYEES OSCHNER HEALTH PLAN OXFORD HEALTH PACIFICARE LIFE AND HEALTH PAI PAN-AMERICAN LIFE INSURANCE CO PEACE CORPS HEALTH BENEFIT PROGRTAM PENNSYLVANIA LIFE PEOPLES HEALTH PERRIER AND LACOSTE PHILADELPHIA AMERICA LIFE INS PHYSICIANS LIFE PHYSICIANS MUTUAL INSURANCE CO PINNACLE HEALTH CLAIMS MANAGEMENT PIPELINE INDUSTRY BEN. FUND PPO PLUS, LLC PPOM PREFERRED BENEFIT ADMIN PREFERRED HEALTH SYSTEMS PRIMARY PHYSICIAN CARE PRINCIPAL FINANCIAL GROUP PRIORITY 1 PRUDENTIAL LIFE PYRAMID CLAIMS PYRAMID LIFE RABALAIS, HANNA & HEBERT RAIL ROAD MEDICARE REHABCARE OF LA RELIANCE STANDARD LIFE INS CO RISK MANAGEMENT SERVICES ROYAL EMBESSY OF SAUDI ARABIA RURAL CARRIER SAFEGUARD SCHLUMBERGER INTERNATIONAL SEAFARERS SECURE HORIZONS SECURITY LIFE SELF INSURED SERVICES COMPNAY SENTINEL LIFE SHEET METAL WORKERS FUND SHELTER LIFE INSURANCE COMPANY SIERRA HEALTH AND LIFE SOCIETY OF THE DIVINE WORLD SOUTHERN BENEFIT SERVICES LLC SOUTHERN FIRE PROTECTION STANDARD LIFE STARMARK STATE FARM MUTUAL INSURANCE STERLING OPTION 1 STERLING OPTION II STERLING OPTION III STUDENT ASSURANCE SERVICES SUMMIT CLAIMS Superior Vision Plan TENET CHOICES 65 TEXAS IMPERIAL THE MEGA LIFE & HEALTH INS CO TIME INSURANCE TODAY'S OPTIONS TOTAL PLAN SERVICES INC TOWER LIFE INSURANCE COMPANY TRANSAMERICA LIFE TRANSAMERICA LIFE TRICARE SOUTH REGION TRUE CHOICE USA TRUSTMARK INSURANCE COMPANY UHC-SHARED SERVICES UHC MEDICARE SOLUTIONS UMR UMR--FRANCISCAN MISSIONARIES UNICARE UNIFORM MEDICAL PLAN UNITED AMERICAN UNITED CLAIM SOLUTIONS UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED HEALTHCARE UNITED HEALTHCARE INTERGRATED SERVICES UNITED MEDICAL RESOURCES UNITED TEACHER ASSOCIATES UNITED WORLD LIFE INS CO UNIVERA HEALTHCARE UNIVERSAL HEALTH CARE, INC. USAA LIFE INS CO. VANTAGE HEALTH PLAN, INC VERITY VSP WAUSAU BENEFITS WEB-TPA WELLCARE WELLS FARGO TPA WESTERN& SOUTHERN WINDSOR STERLING WOODMEN OF THE WORLD WORKERS COMP WORLD INSURANCE WPS-VA
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

Medical History

Personal History

How Old is Current Prescription?:

Ever Worn Contact Lenses?

Type of CLs worn in past:

none Disposables Extended Wear Gas Permeables Gas Perm Bifocals Gas Perm Bitorics Gas Perm FS Toric Monovision - Soft Monovision - Disposables Monovision - Gas Perm No CL Hx Soft Daily Wear Soft Torics Other

Last Eye Exam Date with Doctor:

Last Medical Exam Date with Doctor:

Hobbies:

Review of Systems

Smoking Status:

Unknown if Ever Smoked Current Every Day Smoker Current Some Day Smoker Former Smoker Never Smoker Smoker, Current Status Unknown Other

Do You Drink Alcohol?:

Occasionally Never Regularly Other

Preferred Language:

English (Declined) Spanish Other

Ethnicity:

Not Hispanic or Latino (Declined) Hispanic or Latino Other

Exposure to Infectious Disease?

Do you currently have any of these problems?

General
Fever, Weight Loss/Gain:	No Yes
(Skin) Shingles:	No Yes

Endocrine
Thyroid/Other Glands:	No Yes
Immune Problems:	No Yes

Blood/Lymph
Anemia:	No Yes
Bleeding Problems:	No Yes

Neurological
Headache:	No Yes
Migraine:	No Yes
Seizures:	No Yes
Multiple Sclerosis

Eyes
Blurred Vision:	No Yes
Burning:	No Yes
Gradual Vision Change:	No Yes
Sudden Vision Change:	No Yes
Chronic Infection/Stye:	No Yes
Distorted Vision:	No Yes
Dryness:	No Yes
Double Vision:	No Yes
Excess Tearing/Watering:	No Yes
Eye Fatigue:	No Yes
Eye Pain/Soreness:	No Yes
Flashes:	No Yes
Floaters:	No Yes
Foreign Body Sensation:	No Yes
Itching:	No Yes
Loss of Vision:	No Yes
Loss of Side Vision:	No Yes
Light Sensitivity/Glare:	No Yes
Mucous Discharge:	No Yes
Redness:	No Yes
Sandy/Gritty Feeling:	No Yes

Gastrointestinal

Diarrhea:	No Yes
Constipation:	No Yes
Kidney/Bladder Problems:	No Yes

Ear/Nose/Throat
Allergies/Hay Fever:	No Yes
Chronic Cough:	No Yes
Dry Throat/Mouth:	No Yes
Post-Nasal Drip:	No Yes
Runny Nose:	No Yes
Sinus Congestion:	No Yes

Respiratory
Asthma:	No Yes
Chronic Bronchitis:	No Yes
Emphysema:	No Yes

Cardiovascular

Aneurysm:	No Yes
Diabetes:	No Yes
COPD:	No Yes
Cong. Heart Failure:	No Yes
Heart Attack:	No Yes
Heart Pain:	No Yes
Hypertension:	No Yes
Stroke	No Yes

Bones/Joints/Muscles

Osteoarthritis:	No Yes
Joint Pain:	No Yes
Muscle Pain:	No Yes
Rheumatoid Arthritis:	No Yes

Eye History
Amblyopia	No Yes
Diabetic Eye Disease:	No Yes
Cataracts:	No Yes
Crossed Eye:	No Yes
Glaucoma:	No Yes
Macular Degeneration:	No Yes
Retinal Detachment:	No Yes
Retinal Disease:	No Yes
Thyroid Eye Disease:	No Yes
Other:	No Yes

Family History

Amblyopia:	No Yes
Blindness:	No Yes
Cataract:	No Yes
Crossed Eye:	No Yes
Glaucoma:	No Yes
Macular Degen:	No Yes
Macular Detach:	No Yes
Retinal Disease:	No Yes
Arthritis:	No Yes
Cancer:	No Yes
Diabetes:	No Yes
Heart Disease:	No Yes
High Blood Pressure:	No Yes
Kidney Disease:	No Yes
Lupus:	No Yes
Thyroid Disease:	No Yes
Other:	No Yes

Submit Data

Have you been diagnosed positive for COVID-19, or been presumed positive?
Yes No

Do you have any current symptoms of COVID-19?
Yes No