Demographics

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

* Address: * City:   * State:  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   * ZipCode:

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. Rev. Miss

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 AARP MEDICARE COMPLETE AETNA HMO AETNA MEDICARE Aetna TRS AETNA US HEALTHCARE Aetna Whole Health Accountable Care Network ASSURANT AVESIS BCBS DISCOUNT PLAN/EYEMED BCBS HMO Benefit Planners BENESIGHT Blue Cross Blue Shield of Texas BLUE MEDICARE PPO Blue Premier HMO BOON CHAPMAN Care Improvement Plus CIGNA HEALTHCARE Clover Medicare Advantage Plan/EyeQuest COMP BENEFITS CONNECTICUT GENERAL Covenant Administrators DR. LI COMANAGE Dr. WHITSETT COMANAGE EYEC-ONIC EYEMED Eyetopia FORTIS PHCS Gallagher Benefit Administrators GEHA GOLDEN RULE GPA GREATWEST GROUP& PENSION ADMINS Guardian Health Insurance GWH CIGNA H A S HEALTHSMART BENEFIT SOLUTIONS(PHCS) Humana Choice Care HUMANA GOLD CHOICE(MEDICARE) HUMANA MEDICARE TRS LIONS CLUB Mail Handlers MAIL HANDLERS BENEFIT PLAN Medicare - Part B - NONE MEDICARE SUPPLEMENT Memorial Hermann Health Solutions MES MIDWEST SECURITY ADMINISTRATORS,INC. MISCELLANEOUS INS. NIPPON LIFE INSURANCE CO OPTICARE PERFORMAX PHCS Premier Eye Care Principal Life Insurance Co. RR Medicare Safeguard SECURE HORIZONS SPECTERA SUPERIOR VISION The MEGA Life & Health TIME INSURANCE CO. TML Intergovernmental Tower Life Insurance Co. TRICARE MILITARY TRIWEST UMR Unicare UnitedHealthCare US Family Health Plan Vision Service Plan WAUSAU BENEFITS, INC. WEB TPA
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 MEDICARE COMPLETE AETNA HMO AETNA MEDICARE Aetna TRS AETNA US HEALTHCARE Aetna Whole Health Accountable Care Network ASSURANT AVESIS BCBS DISCOUNT PLAN/EYEMED BCBS HMO Benefit Planners BENESIGHT Blue Cross Blue Shield of Texas BLUE MEDICARE PPO Blue Premier HMO BOON CHAPMAN Care Improvement Plus CIGNA HEALTHCARE Clover Medicare Advantage Plan/EyeQuest COMP BENEFITS CONNECTICUT GENERAL Covenant Administrators DR. LI COMANAGE Dr. WHITSETT COMANAGE EYEC-ONIC EYEMED Eyetopia FORTIS PHCS Gallagher Benefit Administrators GEHA GOLDEN RULE GPA GREATWEST GROUP& PENSION ADMINS Guardian Health Insurance GWH CIGNA H A S HEALTHSMART BENEFIT SOLUTIONS(PHCS) Humana Choice Care HUMANA GOLD CHOICE(MEDICARE) HUMANA MEDICARE TRS LIONS CLUB Mail Handlers MAIL HANDLERS BENEFIT PLAN Medicare - Part B - NONE MEDICARE SUPPLEMENT Memorial Hermann Health Solutions MES MIDWEST SECURITY ADMINISTRATORS,INC. MISCELLANEOUS INS. NIPPON LIFE INSURANCE CO OPTICARE PERFORMAX PHCS Premier Eye Care Principal Life Insurance Co. RR Medicare Safeguard SECURE HORIZONS SPECTERA SUPERIOR VISION The MEGA Life & Health TIME INSURANCE CO. TML Intergovernmental Tower Life Insurance Co. TRICARE MILITARY TRIWEST UMR Unicare UnitedHealthCare US Family Health Plan Vision Service Plan WAUSAU BENEFITS, INC. WEB TPA
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 MEDICARE COMPLETE AETNA HMO AETNA MEDICARE Aetna TRS AETNA US HEALTHCARE Aetna Whole Health Accountable Care Network ASSURANT AVESIS BCBS DISCOUNT PLAN/EYEMED BCBS HMO Benefit Planners BENESIGHT Blue Cross Blue Shield of Texas BLUE MEDICARE PPO Blue Premier HMO BOON CHAPMAN Care Improvement Plus CIGNA HEALTHCARE Clover Medicare Advantage Plan/EyeQuest COMP BENEFITS CONNECTICUT GENERAL Covenant Administrators DR. LI COMANAGE Dr. WHITSETT COMANAGE EYEC-ONIC EYEMED Eyetopia FORTIS PHCS Gallagher Benefit Administrators GEHA GOLDEN RULE GPA GREATWEST GROUP& PENSION ADMINS Guardian Health Insurance GWH CIGNA H A S HEALTHSMART BENEFIT SOLUTIONS(PHCS) Humana Choice Care HUMANA GOLD CHOICE(MEDICARE) HUMANA MEDICARE TRS LIONS CLUB Mail Handlers MAIL HANDLERS BENEFIT PLAN Medicare - Part B - NONE MEDICARE SUPPLEMENT Memorial Hermann Health Solutions MES MIDWEST SECURITY ADMINISTRATORS,INC. MISCELLANEOUS INS. NIPPON LIFE INSURANCE CO OPTICARE PERFORMAX PHCS Premier Eye Care Principal Life Insurance Co. RR Medicare Safeguard SECURE HORIZONS SPECTERA SUPERIOR VISION The MEGA Life & Health TIME INSURANCE CO. TML Intergovernmental Tower Life Insurance Co. TRICARE MILITARY TRIWEST UMR Unicare UnitedHealthCare US Family Health Plan Vision Service Plan WAUSAU BENEFITS, INC. WEB TPA
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

PATIENT INFORMATION

Referred by:
Family Members:
Last Eye Doctor/Phone:
Family Doctor/Phone:
Endocronologist/Phone:
Pharmacy Name:
Pharmacy Number:
* Race:	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other
* Preferred Language:	English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other
* Ethnicity:	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other
* Gender:

Social History (required for insurance)

* Do you smoke?  Never smoker (<100 lifetime cigarettes or equivalent quantity of cigar or pipe smoke) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other
Have you been infected with: HIV    Herpes Simplex    Hepatitis

Height:
* Ft. * In.
Weight:
* Lbs.
Have you ever had any surgeries?


REVIEW OF SYSTEMS (required for insurance) Place check beside the following that apply or mark NONE below:

Constitutional (fever, weight gain/loss)
Ear/Nose/Throat (Hearing loss, Sinus)
Neurological (migraines)
Endocrine (thyroid, diabetic)
Respiratory/Pulmonary (asthma, bronchitis)
Cardiovascular, Vascular (Blood Pressure, cholesterol)
Gastrointestinal (colitis, crohns disease)
Genitourinary (bladder, prostate)
Bones/Joints(joint pain, rheumatoid arthritis)
Lymphatic/Hematologic (anemia, bleeding)
Allergic/Immunologic (sjogrens)
Psychiatric (depression)
NONE

MEDICAL HISTORY

* Are you allergic to any medications?
NO KNOWN    Yes

Please list:
List all current medications:
None

Please check if any of the following pertain to you:

Pulmonary Disease    Asthma    Diabetes    Hypertension    COPD    Heart Problems

* Are you Pregnant or nursing?   NO    Yes

GENERAL HEALTH:

Do you feel that your general health is:   Good    Poor    Fair

Family Medical History: Cancer Hypertension Arthritis Asthma Diabetes COPD

Eye History

Eye History (Are you experiencing any of the following symptoms?

* Please check all that apply.

Dryness Tearing Sty Double Vision	Blurred Vision Discharge Light Sensitivity Eye Lid Itch	Glare Flashers/Floaters Foreign Body Sensation Eye Pain	Droopy Eyelid(s) Eyeball Itch Variable Vision Redness	Sting, Burn Loss of Lashes Distorted Vision
Other:

Have you had any eye surgery, laser treatments or eye injury?
No    Yes
If yes, please explain:

* Have You been diagnosed with Diabetes?
Yes No Type 1 Type 2 Pre - Diabetes
Have you been prescribed eye drops?
No    Yes

If yes, what drops and how often:

* Do you wear prescription glasses?
Yes NO
When do you wear your glasses?
All the time    Computer    Reading/Near     Distance Only

Other:

How old is this prescription?


Do you see well with this prescription?
No    Yes

Do you wear contacts? If so what brand:


* Right Eye RX:
* Left Eye RX:

Are you interested in contacts? No    Yes

What type of glasses would you like and for what types of activities:

FAMILY HISTORY

Do you or a blood relative have:

	Self	Relative
Glaucoma	NO   Yes	NO   Yes
Cataracts	NO   Yes	NO   Yes
Lazy Eye	NO   Yes	NO   Yes
Retinal Disease	NO   Yes	NO   Yes
Macular Degeneration	NO   Yes	NO   Yes
Corneal Disease	NO   Yes	NO   Yes

Optomap

Optomap Information

As part of your annual eye examination, our doctors will assess the health of the anatomical structures at the back of the eye including your optic nerve, macula, blood vessels, and other various retinal tissues. This portion of the examination is critical in detecting vision problems, diagnosing ocular diseases such as glaucoma and macular degeneration, as well as screening for systemic health conditions such as diabetes and high blood pressure. There are two primary methods we utilize to evaluate your retinal health, as outlined below.

•  Standard Dilation - Drops are instilled into your eyes that (over a period of 20-30 minutes) will dilate the pupils and allow the doctor to view your retina with a series of lenses. Although the doctor can only see a small portion of the retina at any given moment, an evaluation of the entire retina is possible utilizing various lenses and eye positions. Side effects of the dilation drops typically include light sensitivity, and blurred vision for 4-6 hours following the dilation.

•  Optomap Imaging - The "optomap" is a widefield retinal imaging system designed to provide you and your doctor with archivable images of your retinal structures. The optomap requires no dilation drops to obtain the images, takes only seconds to perform, and the results are instantaneous. When you choose optomap as a part of your eye examination, your doctor will review your retinal health with you in the exam room, and we will maintain your widefield retinal photos in our database to serve as a basis of comparison for years to come: this means earlier detection of ocular health complications than would otherwise be possible without this technology. For these reasons, Optomap is the preferred option for all of our patients. However, please be aware that Optomap imaging may not be a covered service under some vision insurance plans.

* Medical Ocular Diagnosis: We will dilate and take enhanced Optomap Images and file to your medical insurance carrier.

Policies and Consents

Thank you for choosing Woodlands Eye Associates for your eye health needs. We would like to take this moment to discuss our financial policies and consents. HIPAA Consent to Use or Disclose Health Information For Treatment, Payment, and Healthcare Operations
In the course of providing health care to you, we may need to create, receive, and/or store health information
that potentially identifies you. It is often necessary to use and disclose this health information
in order to treat you, to obtain payment for services, and to conduct healthcare
operations involving our office. A comprehensive "Notice of Privacy Practices" is
available from our office that describes in detail the use and disclosure of such health
information. You are free to refer to this notice at any time before you sign this consent
document. As described in our "Notice of Privacy Practices" the use and disclosure of
your health information is necessary for you to receive ongoing care from this office or
in conjunction with other health professionals. Our "Notice of Privacy Practices" will be
updated when our privacy practices changes. Whenever our practices change you may
obtain an updated copy from our offices, or from our website at
www.woodlandseye.com. When you sign this consent form, you agree to the use and
disclosure of your health information to treat you, to obtain payment for our services,
and to perform healthcare operations.


Insurance Consent I hereby consent to the release of medical information (self,
child/dependent, or family member) to the insurance companies responsible for my
care. I understand that while my medical records are confidential, information within
these records may be required by my insurance company in order to facilitate care, and
will only be released at their request. I understand that by signing this consent form, I
am allowing my medical information to be released upon my insurance company's
request, for the purpose of healthcare operations (including but not limited to, provider
review function, claims payments, and quality assessment).


Insurance Services - Woodlands Eye Associates is in network as preferred providers
with many medical health plans and vision discount plans. Woodlands Eye Associates
will make every effort to verify coverage and benefits prior to your visit with the
physician. If we are unable to verify benefits, we will ask you to pay in full or
reschedule your visit until the verification can be obtained. This verification will be
used to estimate your financial responsibility; however, this verification is not a
guarantee by your health plan of coverage or payment. If your health plan denies any
part (or the entirety of your claim), you agree that you are financially responsible for the
balance.


Medical Insurance - Medicare, United Health Care, Blue Cross, Aetna, Cigna, etc.
We bill medical insurance when you present a medical related complaint such as: itch,
burn, dryness, redness, eye pain, etc. that may or may not require treatment and
monitoring. We will also bill your medical insurance carrier for medical
diagnosis/findings such as Diabetes, Glaucoma, Cataracts, Floaters, Macular
Degeneration, etc. HMO Policies: We will help assist you in obtaining a referral
authorization from your Primary Care Physician (PCP) by faxing the detailed
information required for your visit. If we cannot obtain an authorization/referral for your
visit, you will be billed for the services rendered. Reminder: If you have not established
care with your designated Primary Care Physician (PCP) for your HMO medical
insurance, you may be required to schedule an appointment with your Primary Care
Physician (PCP) prior to authorizing referrals. Primary Care Physicians (PCP) may have
their own policies in place to issue referrals for services.

If you present with both a vision complaint and a medical complaint, we will
bill to the appropriate insurance as indicated in your insurance by-laws.

Medicare Notice - We are Medicare participating providers; therefore, we will bill
Medicare directly. However, as with any insurance carrier, you will be responsible at the
time of services for payment of:

The annual deductibles

Co-payments

Charges for non-covered services: Example: $39.00 Refraction fee (may not be
covered by Medicare supplement plan and/or vision discount plan).

A refraction is required to determine your best corrected vision. We will conduct
refraction whether you wear glasses or not.


You will also be asked to sign an Advanced Beneficiary Notice (ABN) form in the
event a service is provided, which we know is not covered by Medicare or your
supplemental insurance.

Important: Please let us know if you signed up for a Medicare Advantage Plan.
Traditional Medicare and Medicare Advantage Plans are not the same. If you
signed up with a Medicare Advantage Plan, you no longer have traditional
Medicare.

Vision/Routine Insurance - VSP, Superior, Eyemed, Spectera, etc. These discount
plans are billed for routine eye exams, glasses or contacts lenses. They do not cover
medical related complaints or conditions. Most vision discount plans require an
authorization before your services are rendered. If we cannot obtain an authorization,
you will be responsible to pay for both professional services as well as eye wear
materials.

Private Pay Patients - We will provide you with itemized receipts for all transactions if
you chose to file your own claim to your insurance carrier.

Contact Lens Policy - (only applicable for patients desiring contact lenses) All contact
lenses are "medical devices" according to federal law, and as such, require a proper
fitting (in addition to the routine examination) to ensure ocular health. For patients who
would like to be fit with contact lenses, the doctor performs a comprehensive eye exam
to check the overall health of your eyes, as well as additional testing to assess the fit,
prescription, and type of contact lens that best suits your eyes. The contact lens fitting
fee ranges from $69.00 on up depending on the complexity of your prescription
needs. This fee includes trial contact lenses for the purpose of prescription changes
and follow-up visit(s) when needed. Fees that are paid for examinations, contact lens
evaluation/fitting, and progress checks for contacts lenses are non-refundable. If you
are brand new to contacts, a one-time fee of $49.00 is charged for a Contact Lens
Training in our office. A period of 60 days is allotted for all contact lens follow-up
visits. A separate charge for any additional visits past the 60-day time frame may apply.
Your prescription will be finalized once the doctor has determined an appropriate and
healthy lens that you are satisfied with, and you have expressed to us that you would
like to proceed with an order. Contact Lens Exams are required annually along with
a Comprehensive Eye Exam. A contact lens prescription is valid for 1 year.

Payment- Payment of copays, deductibles, coinsurance, out of pocket or non-covered
services are due upon check out. We always obtain the most accurate amounts due
from your insurance carrier. We will issue a refund or bill your account once we receive
your explanation of benefits (EOB) from your insurance carrier. You will receive a
detailed statement in the mail regarding your portion of the bill.

Payment Methods - For your convenience we accept cash, pre-printed NON temporary
checks, Visa, MasterCard, American Express, Care Credit, Discover, Flex
Spending/HSA accounts and online bill pay as a form of payment.

Claim Denials - Please be aware that certain office products, procedures or services
may not be covered, or may be considered not medically necessary by your health plan.
You are responsible for payment of these services. Such procedures and products
include but are not limited to: contact lens fittings, specialty
contact lenses, specialty eye glass lenses and designer frames, glaucoma scans, visual fields or other medically
necessary testing. You will be billed if we obtain a denial from your insurance company
and/or we have not received payment from the insurance company within 60 days of
our filing your claim.

Past Due Accounts - If your account becomes past due, we will take necessary steps
to collect this debt. We are here to help.

We encourage you to contact our insurance specialists to discuss your bill as needed.

Medical Plaza Office Location:    Christina
                                                              Office Phone: 281-367-2020
                                                              Email: insurance@woodlandseye.com
Panther Creek Office Location:    Mollie
                                                              Office Phone: 281-367-5335
                                                              Email: mollie@woodlandseye.com

Our insurance specialists are available Monday-Friday 8:30-5:00pm. If they are
   unavailable to take your call, please leave a detailed message and they will
   return your call within the next business day.

NSF Checks - There will be a $25 service fee charged to your account if your check is
returned by your bank for any reason. Upon notification from our office of your returned
check, payment of the entire balance is due immediately. We will accept payment in the
form of credit card, cash, or money order.
Photo & Social Media Woodlands Eye Associates uses a variety of resources
to publicize events, products, and services. Should you object to a photograph or other
electronic image of you or your child on social media, the company website, marketing
brochures, publications, newsletters, or other media coverage prepared for use both
inside and/or outside Woodlands Eye Associates, please notify our office. We would
love for you to share your experiences at Woodlands Eye Associates with your family
and friends!

Please check, sign, and date that you have read and agree to our policies and click the submit button to complete your online forms. Thank you!
*I have read and agree to the policies and consents outlined above.
Patient Signature:
Date:

Submit Data