New Patient Form

Demographics

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

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:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Copeland, Seth Dr. Winters, Benjamin C. Dr. Peterson, Charles Dr. Lee, Kevin Dr. Stromme, Jeanette Dr. Ricks, Douglas Dr. Yakima, Eye Care	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

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 No Name AARP Advance PCS Advantica Advantra EDI Payor #25152 Advenitist Risk Management-TX Adventist Risk Management-CA Adventist Risk Management-PA Aetna Alaska Machinists Health & Welfare Trust AlaskaCare / Wells Fargo Insurance Services Allegiance AmeriBen Solutions American Insurance Administrators American Pioneer American Republic Insurance Company Anthem Blue Cross APWU APWU - medco Arizona Foundation for Medical Care-Payor 86062 ARM, Ltd. Northwest ASEA/AFSCME Local 52 Health Benefits Trust Asuris Northwest Health Bakery & Confectionary Health Bankers Fidelity Bankers Life and Casualty Company Benefit Management Boulder Administrative BRMS Carpenters Health & Sercurity Plan of Western Washington Payor 91131 CBSA Performax WebMD#41124 Cement Masons & Plasters Ceres Group Inc ChampVA Payor ID 84146 Chesterfield Resources, INC Christian Fidelity CIGNA-Medicare Access-Payor ID 86033 CIGNA (not medicare access) Columbia Community Care Columbia United Providers Community Health Plan - Payor CHPWA Connecticut General Life Insurance Continental General Insurance Co Contract Health Services Conventry Health Care Cooperative Benefit Administrators EDI# 52132 Coresource Dakota Care Department of Veterans Affairs (VA Vouchers) Direct Dental Admintrators LLC Division of Disability Determination Services EBA and M Corporation Fiesta Foods C/O PHTech Fire Fighter Health Care Trust First Choice-Electronic Payor 91131 First Choice-Group# YAK 80000 First Choice-PHCO First Choice-Walgreens First Choice - BIMart Payor #61271 First Choice - EBMS First Choice - Mercer First Choice - Painters First Choice - Providence Preferred First Choice - Select Benefit Admin First Choice - Sisco First Choice - UEBT First Choice - WebMD 13310 First Choice - WSAD First Choice - WSHIP First Choice -TX First Choice #85729 First Choice Electronic Payor # 91078 First Choice Health Administrators First Choice Health Network, Inc First Choice Mutual of Omaha First Choice Payor #91136 PSEW Health Trust First Choice Seattle Plumbing & Pipefitting Trust First Choice UFCW First Choice United Medical Payor #31107 FISERV HEALTH #39026 Government Employees Hospital Association Group Administrators LTD-Payor ID #36338 Group Health Payor#91051 GTESS Harco National Insurance Company Health Net *NOW BILL FC PAYOR 91131 Healthcomp HealthComp- Platt Electric Only HMA Payor ID # HMA01 Humana Claims IBEW/Western Utilities IBU National Health Benefit Trust Inland Empire Electrical Workers Trust Kaiser Permanente KPS Health Plans LEOFF Health & Welfare Lifewise Healthplan of Washington Lifewise Of Oregon Lincoln Heritage LLUAHS Dept. of Risk Management Locals 302 and 612 I.U.O.E EDI # 91136 Lumenos Maksin Management Corp-WSU Marquette Life Marsh Advantage Masonry Welfare Trust MBA of MD, Inc EDI 37298 MEBA Medical Plan (Vision) Medicaid Medicare Medicare - RR Medico MEGA Life & Health Insurance Co Meritain Health MidWest National Life Morumental Life Insurance Mutual of Omaha MVP Health Care NALC Health Benefit Plan Payor #53011 New Insurance New Insurance NorthStar Administrators Northwest Administrators Northwest IAM Trust Northwest Laborers Northwest Sheet Metal Workers NW Benefit Network Vision ODS Olympic Health Management Operating Engineers Health and Security Fund P5 Health Plan Solutions Pacific Source Health Plans Pacific Underwriters Phillips Administrative Service, Inc Premera Blue Cross Prestige Care, Inc Principal Life Insurance Co ID #61271 Pyramid Life Regence-Federal Employees Regence-WA Regence Group Adiminstrators (RGA) Regence Healthy Options Retiree's Welfare Trust Royal Neighbors of America Santa Fe Employee Hospital Assoc. Secure Horizons Security Life Ins. Co. of America- Payor ID CX092 Shasta Adminstrative services Sierra Standard Insurance Co., FCHN State Farm Sterling Sterling Medicare Select The Employee Painters Trust Health & Welfare Plan The Local 598 Health Trust The Mail Handlers Benefit Plan ID #62413 Timber Products Manufacturers Tongass Timber Trust TPSC Payor #91078 TransAmerica Life Insurance Claims Processing Triwest UniCare Payor ID # 80314 Uniform Medical Plan NOW BILL REGENCE United American Insurance United Health Care-WA United Health Care (not Local) United Health Care (StudentResource Payor ID 74227) United Medical Resource United Medical Resource Payor ID# 39026 Untied American Insurance Co - Teamstar Uprehs Payor ID #87042 USAA Life Insurance Company VSP WA/ID Carpenters Employers Health & Security Trust Fund Washington-Idaho Operating Engineers Trust Fund Washington Employers Trust #37294 WEB MD Payer 91136 WEBTPA - Morumental Life Insurance Co Welfare & Pension Admin - Medicare Wellcare Wenatchee Valley Medical Center Managed Care Claims Western Grocers Benefits Trust WMI/TPA Care World Insurnace Company Zenith Administators
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:
Employer/School:

Medical History

What are your hobbies?

Eye History: Do your eyes itch, burn, or water? Do you see flashes of light, floaters, or double? Have you had any surgeries or injuries?

What eye medications do you take?

Who was your last eye doctor?

Costco Cascade Eye Center Lenscrafters Wal-Mart Shopko Sears

Who is your primary care physician?

What medications are you taking?

Do you have any medication or seasonal allergies?

Do you smoke, drink, or use recreational drugs?