Demographics

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

Address:
City:		State/ZipCode	TN KY GA AR MS

Home Phone:		Work Phone:
Other Phone:		Alerts:
SSN		Email
Birthday		Occupation
Gender	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Married Single Widowed	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Kizer, Lewis	Misc/Guardian

Billing Information

Billing Address is Different Than Above:

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

Address

City	State	ZipCode
	TN KY GA AR MS

Home Phone:
Work Phone:

Insurance 1

Insurance Information

Insurance Name:	None Aag / American Admin. Group AARP Claims / United Healtcare Admiral Life Insurance Co of America Advantra Freedom Aetna AFLAC American Health Group, Inc. American Medical Security American Pioneer Life Ins Co American Republic Insurance Company AmeriChoice Assurant Health Aultcare Auxiant Az Pipe Trades Health And Welf Bakery & Confectionary Union Bankers Fidelity Life Ins Co. Bankers Life Claims BCBS-1 BCBS of TN Claims Beech Street Benefit Administrative Systems Benefit Planners BlueCare Boilermakers Nat Health Claims Bradford Lion's Club Central St.health And Welfare Champva Center Choice Benefits Cigna Cigna Connecticut General Cigna Healthcare 1 Coast To Coast Vision Plan Cole Vision Colonial Penn Health Claims Combined Ins Co Of Am Combined Ins Co Of America Conseco National Life Ins Co Consociates Dansig Continental General Insurance Continental Life Cooperative Benefits Administrators CoreSource Inc. Corestar Covenant Administrators Inc. Coventry Health Care Dana /american Health Group Dana Corp/american Health Grou Davis Vision / Vision Processing Definity Health Department of Children's Services Diversified Group Administrators, Inc. DME MAC Dyer Lion's Club Dyersburg St Com Workforce EBMS Emc EMERSON ELEC. CO BENEFIT TRUST Employee Benefit Consultants & Admin Epoch Group Eyemed Vision Fallon Benefits Att: Renee Leggitt Family Life Insurance Company First Administrators First Health Fortis Insurance Company FRA Insurance Plans Ge Life And Annuity Assurance Gen Motors/metlife/medicare Pt Georgia Life & Health Ins Co Golden Rule Goodyear Medical Ins Benefits Goodyear Vision Metlife Government Employees Hosp Asso Great-west Health Plan Great West Guarantee Trust Life Ins Co Guardian-general Metal Pro. Co Health Choice Lebonheur Health Cost Solutions Health Partners Health Partners Reprice Healthlink, Inc. HM Benefits Administrators, INC Humana Claims Office Humana Gold Choice Humana Health Care Claims Humana Specialty Benefits IAC Illinois Central Hospital Asso Insurance Center KCL Benefit Solutions Lason, Inc. Lincoln Heritage Life Ins Co Mahoney Benefits Administrated Medicaid / Tenncare Att: Prov. Relations Medical Benefits Administrators Medicare TN Part B Claims Medina Lions Club Memphis Managed Care - TLC Meritian Health Met Life Vision Mid-south Insurance Company Mid-West Nationall Life Ins Co Of TN Milan Lion's Treasurer MMS MMS/ Fiserv Health MSAG Mutual Of Omaha Companies National Foundation Life New Era Life Ins. Co. Claims Ngs America, Inc. NHC Healthcare of Milan Nippon Life Ins. Of America North American Administrators Novanet Optima Health Insurance Company Pacific Life & Annuity Benefits Office Palmetto GBA/ Cigna Gov Services PHCS Phoenix Medical Phoenix Vision Physicians Mutual-claims Pioneer Life Policy Benefits Pittman & Associates, Inc. Plunley Comp. Inc. Ins. Claims POMCO Principal Financial Group Principal Life Insurance Company Provident Life & Acc. Ins. Co. Qual Choice Of Arkansas Inc Railroad Medicare Raniey, Kizer,butler, Reviere Reserve National Retiree Medical Insurance Plan Royal Neighbors of America Rural Carrier Benefit Plan S.council Of Industrial Worker Select Benefit Adm of America Signature Health Alliance Southland National Insurance Corporation Southwest Carpenters Spectera Vision Claims Spectra Claims Standard Life And Accident Co. Star HRG State Farm Health Insurance State Farm Insurance Company State Farm Medicare Supplement State Farm Mutual Auto State Mutual Insurance Company Sterling Investors Life Insurance Compan Sterling Life Insurance Company Stirling & Stirling Sun Healthcare Group, Inc. Superien Health Network Tdhs Div Of Rehab C\o B. Baker Tecumseh Aetna Life Ins Co TennCare Select THC The Loomis Company/ SKF USA The Mail Handlers Benefit The Mail Handlers Benefit Plan Time Ins. Co. Todays Options Pyramid Life Insurance Co Total Claims Solutions Tower Auto -- Benesight Tri Point --block Vision Claim Tricare For Life Tricare Prime And Standard UA Local Union No 614 ---Cigna UMR Umwa Un Healthcare 1 Un Healthcare Of Tennessee Unicare Unicare Association Services Unicare Senior Services Unicare/ Ccn Tn Union Bankers Ins. Co. Unisys / Aetna Us Healthcare United American United Commercial Travelers United Dom/ceco/ Aetna United Food And Comm. Workers United Healthcare United Healthcare Empire Plan United Healthcare GA United Teachers Associates United World Life Insurance USA Health Network USAA Life Insurance Company Veterans Adm/ 136g Fee Base Vision Care Vision One Vision Service Plan Washington National Ins. Co. Wausau Benefits Wells Fargo TPA Willis Corroon Adm Services Workman Comp World Insurance Company Wozniak Industries Humana
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Primary Insured Name:	Last, First MI
Patient's relationship to Primary Insured:	Spouse Child Other
Primary Insured Gender:	Male Female
Primary Insured Address:
Primary Insured City: State: Zip:
Primary Insured Phone Number:
Primary Insured Birthday:
Primary Insured Employer/School:

Insurance 2

Insurance Information

Insurance Name:	None Aag / American Admin. Group AARP Claims / United Healtcare Admiral Life Insurance Co of America Advantra Freedom Aetna AFLAC American Health Group, Inc. American Medical Security American Pioneer Life Ins Co American Republic Insurance Company AmeriChoice Assurant Health Aultcare Auxiant Az Pipe Trades Health And Welf Bakery & Confectionary Union Bankers Fidelity Life Ins Co. Bankers Life Claims BCBS-1 BCBS of TN Claims Beech Street Benefit Administrative Systems Benefit Planners BlueCare Boilermakers Nat Health Claims Bradford Lion's Club Central St.health And Welfare Champva Center Choice Benefits Cigna Cigna Connecticut General Cigna Healthcare 1 Coast To Coast Vision Plan Cole Vision Colonial Penn Health Claims Combined Ins Co Of Am Combined Ins Co Of America Conseco National Life Ins Co Consociates Dansig Continental General Insurance Continental Life Cooperative Benefits Administrators CoreSource Inc. Corestar Covenant Administrators Inc. Coventry Health Care Dana /american Health Group Dana Corp/american Health Grou Davis Vision / Vision Processing Definity Health Department of Children's Services Diversified Group Administrators, Inc. DME MAC Dyer Lion's Club Dyersburg St Com Workforce EBMS Emc EMERSON ELEC. CO BENEFIT TRUST Employee Benefit Consultants & Admin Epoch Group Eyemed Vision Fallon Benefits Att: Renee Leggitt Family Life Insurance Company First Administrators First Health Fortis Insurance Company FRA Insurance Plans Ge Life And Annuity Assurance Gen Motors/metlife/medicare Pt Georgia Life & Health Ins Co Golden Rule Goodyear Medical Ins Benefits Goodyear Vision Metlife Government Employees Hosp Asso Great-west Health Plan Great West Guarantee Trust Life Ins Co Guardian-general Metal Pro. Co Health Choice Lebonheur Health Cost Solutions Health Partners Health Partners Reprice Healthlink, Inc. HM Benefits Administrators, INC Humana Claims Office Humana Gold Choice Humana Health Care Claims Humana Specialty Benefits IAC Illinois Central Hospital Asso Insurance Center KCL Benefit Solutions Lason, Inc. Lincoln Heritage Life Ins Co Mahoney Benefits Administrated Medicaid / Tenncare Att: Prov. Relations Medical Benefits Administrators Medicare TN Part B Claims Medina Lions Club Memphis Managed Care - TLC Meritian Health Met Life Vision Mid-south Insurance Company Mid-West Nationall Life Ins Co Of TN Milan Lion's Treasurer MMS MMS/ Fiserv Health MSAG Mutual Of Omaha Companies National Foundation Life New Era Life Ins. Co. Claims Ngs America, Inc. NHC Healthcare of Milan Nippon Life Ins. Of America North American Administrators Novanet Optima Health Insurance Company Pacific Life & Annuity Benefits Office Palmetto GBA/ Cigna Gov Services PHCS Phoenix Medical Phoenix Vision Physicians Mutual-claims Pioneer Life Policy Benefits Pittman & Associates, Inc. Plunley Comp. Inc. Ins. Claims POMCO Principal Financial Group Principal Life Insurance Company Provident Life & Acc. Ins. Co. Qual Choice Of Arkansas Inc Railroad Medicare Raniey, Kizer,butler, Reviere Reserve National Retiree Medical Insurance Plan Royal Neighbors of America Rural Carrier Benefit Plan S.council Of Industrial Worker Select Benefit Adm of America Signature Health Alliance Southland National Insurance Corporation Southwest Carpenters Spectera Vision Claims Spectra Claims Standard Life And Accident Co. Star HRG State Farm Health Insurance State Farm Insurance Company State Farm Medicare Supplement State Farm Mutual Auto State Mutual Insurance Company Sterling Investors Life Insurance Compan Sterling Life Insurance Company Stirling & Stirling Sun Healthcare Group, Inc. Superien Health Network Tdhs Div Of Rehab C\o B. Baker Tecumseh Aetna Life Ins Co TennCare Select THC The Loomis Company/ SKF USA The Mail Handlers Benefit The Mail Handlers Benefit Plan Time Ins. Co. Todays Options Pyramid Life Insurance Co Total Claims Solutions Tower Auto -- Benesight Tri Point --block Vision Claim Tricare For Life Tricare Prime And Standard UA Local Union No 614 ---Cigna UMR Umwa Un Healthcare 1 Un Healthcare Of Tennessee Unicare Unicare Association Services Unicare Senior Services Unicare/ Ccn Tn Union Bankers Ins. Co. Unisys / Aetna Us Healthcare United American United Commercial Travelers United Dom/ceco/ Aetna United Food And Comm. Workers United Healthcare United Healthcare Empire Plan United Healthcare GA United Teachers Associates United World Life Insurance USA Health Network USAA Life Insurance Company Veterans Adm/ 136g Fee Base Vision Care Vision One Vision Service Plan Washington National Ins. Co. Wausau Benefits Wells Fargo TPA Willis Corroon Adm Services Workman Comp World Insurance Company Wozniak Industries Humana
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Primary Insured Name:	Last, First MI
Patient's relationship to Primary Insured:	Spouse Child Other
Primary Insured Gender:	Male Female
Primary Insured Address:
Primary Insured City: State: Zip:
Primary Insured Phone Number:
Primary Insured Birthday:
Primary Insured Employer/School:

Insurance 3

Insurance Information

Insurance Name:	None Aag / American Admin. Group AARP Claims / United Healtcare Admiral Life Insurance Co of America Advantra Freedom Aetna AFLAC American Health Group, Inc. American Medical Security American Pioneer Life Ins Co American Republic Insurance Company AmeriChoice Assurant Health Aultcare Auxiant Az Pipe Trades Health And Welf Bakery & Confectionary Union Bankers Fidelity Life Ins Co. Bankers Life Claims BCBS-1 BCBS of TN Claims Beech Street Benefit Administrative Systems Benefit Planners BlueCare Boilermakers Nat Health Claims Bradford Lion's Club Central St.health And Welfare Champva Center Choice Benefits Cigna Cigna Connecticut General Cigna Healthcare 1 Coast To Coast Vision Plan Cole Vision Colonial Penn Health Claims Combined Ins Co Of Am Combined Ins Co Of America Conseco National Life Ins Co Consociates Dansig Continental General Insurance Continental Life Cooperative Benefits Administrators CoreSource Inc. Corestar Covenant Administrators Inc. Coventry Health Care Dana /american Health Group Dana Corp/american Health Grou Davis Vision / Vision Processing Definity Health Department of Children's Services Diversified Group Administrators, Inc. DME MAC Dyer Lion's Club Dyersburg St Com Workforce EBMS Emc EMERSON ELEC. CO BENEFIT TRUST Employee Benefit Consultants & Admin Epoch Group Eyemed Vision Fallon Benefits Att: Renee Leggitt Family Life Insurance Company First Administrators First Health Fortis Insurance Company FRA Insurance Plans Ge Life And Annuity Assurance Gen Motors/metlife/medicare Pt Georgia Life & Health Ins Co Golden Rule Goodyear Medical Ins Benefits Goodyear Vision Metlife Government Employees Hosp Asso Great-west Health Plan Great West Guarantee Trust Life Ins Co Guardian-general Metal Pro. Co Health Choice Lebonheur Health Cost Solutions Health Partners Health Partners Reprice Healthlink, Inc. HM Benefits Administrators, INC Humana Claims Office Humana Gold Choice Humana Health Care Claims Humana Specialty Benefits IAC Illinois Central Hospital Asso Insurance Center KCL Benefit Solutions Lason, Inc. Lincoln Heritage Life Ins Co Mahoney Benefits Administrated Medicaid / Tenncare Att: Prov. Relations Medical Benefits Administrators Medicare TN Part B Claims Medina Lions Club Memphis Managed Care - TLC Meritian Health Met Life Vision Mid-south Insurance Company Mid-West Nationall Life Ins Co Of TN Milan Lion's Treasurer MMS MMS/ Fiserv Health MSAG Mutual Of Omaha Companies National Foundation Life New Era Life Ins. Co. Claims Ngs America, Inc. NHC Healthcare of Milan Nippon Life Ins. Of America North American Administrators Novanet Optima Health Insurance Company Pacific Life & Annuity Benefits Office Palmetto GBA/ Cigna Gov Services PHCS Phoenix Medical Phoenix Vision Physicians Mutual-claims Pioneer Life Policy Benefits Pittman & Associates, Inc. Plunley Comp. Inc. Ins. Claims POMCO Principal Financial Group Principal Life Insurance Company Provident Life & Acc. Ins. Co. Qual Choice Of Arkansas Inc Railroad Medicare Raniey, Kizer,butler, Reviere Reserve National Retiree Medical Insurance Plan Royal Neighbors of America Rural Carrier Benefit Plan S.council Of Industrial Worker Select Benefit Adm of America Signature Health Alliance Southland National Insurance Corporation Southwest Carpenters Spectera Vision Claims Spectra Claims Standard Life And Accident Co. Star HRG State Farm Health Insurance State Farm Insurance Company State Farm Medicare Supplement State Farm Mutual Auto State Mutual Insurance Company Sterling Investors Life Insurance Compan Sterling Life Insurance Company Stirling & Stirling Sun Healthcare Group, Inc. Superien Health Network Tdhs Div Of Rehab C\o B. Baker Tecumseh Aetna Life Ins Co TennCare Select THC The Loomis Company/ SKF USA The Mail Handlers Benefit The Mail Handlers Benefit Plan Time Ins. Co. Todays Options Pyramid Life Insurance Co Total Claims Solutions Tower Auto -- Benesight Tri Point --block Vision Claim Tricare For Life Tricare Prime And Standard UA Local Union No 614 ---Cigna UMR Umwa Un Healthcare 1 Un Healthcare Of Tennessee Unicare Unicare Association Services Unicare Senior Services Unicare/ Ccn Tn Union Bankers Ins. Co. Unisys / Aetna Us Healthcare United American United Commercial Travelers United Dom/ceco/ Aetna United Food And Comm. Workers United Healthcare United Healthcare Empire Plan United Healthcare GA United Teachers Associates United World Life Insurance USA Health Network USAA Life Insurance Company Veterans Adm/ 136g Fee Base Vision Care Vision One Vision Service Plan Washington National Ins. Co. Wausau Benefits Wells Fargo TPA Willis Corroon Adm Services Workman Comp World Insurance Company Wozniak Industries Humana
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Primary Insured Name:	Last, First MI
Patient's relationship to Primary Insured:	Spouse Child Other
Primary Insured Gender:	Male Female
Primary Insured Address:
Primary Insured City: State: Zip:
Primary Insured Phone Number:
Primary Insured Birthday:
Primary Insured Employer/School:

Medical History

Last eye care provider:		How long since last exam:
Family physician:		If pregnant, how many weeks:
Hobbies:

---

Is there a family history of the following conditions?

	Diabetes	Who?			Retinal Detachment	Who?
	Glaucoma	Who?			Macular Degeneration	Who?

---

Does PATIENT  have a history of the following conditions?

	High Blood Presure		Arthritis		Lazy Eye		Intestinal Disease
	Heart Disorders		Convulsions		Eye Surgery		Skin Disease
	Blood Disorders		Lung Disorders		Eye Tumors		Ear Disease
	Migraine Headaches		Emphysema		Eye Cancer		Ulcers
	Allergy / Hay Fever		Thyroid Disease		Double Vision		Liver Disease
	Urinary Tract Disorders		Kidney Disease		Crossed Eye		Psychiatric
							Blindness

Surgery: Date and Type

---

Does PATIENT smoke?	Yes	No	If so, how many daily?
Does PATIENT drink alcohol?	Yes	No	If so, how much daily?
Is PATIENT allergic to any medications?		Yes No  If so, list specific types:

---

Please list all medications that the PATIENT is currently taking:
Pharmacy name & phone:	Select Pharmacy from this list: Wal-Mart Milan - Phone (731) 686-9322 Fred's Milan - Phone (731) 686-9097 Super D Milan - Phone (731) 686-1557 Flippin Drug Milan - Phone (731) 686-7467 EW James Milan - Phone (731) 686-7411 Hometown Pharmacy Medina - Phone (731) 783-0777 West Carroll Pharmacy Trezevant - Phone (731) 669-3200 Wal-Mart Humboldt - Phone (731) 784-0050 CVS Trenton - Phone (731) 855-2171 Fred's Trenton - Phone (731) 855-9222 Duncan's Pharmacy Dyer - Phone (731) 692-3577 Other - Pharmacy not in list.
If "Other", enter here:

---

Check all that apply:

PATIENT has had radiation therapy to the head and / or neck		PATIENT skips lines frequently when reading
PATIENT is allergic to Latex		PATIENT'S eyes itch often
PATIENT'S eyelids stick together in the morning		PATIENT frequently uses eye drops
PATIENT'S eyelashes have crust like particles often		PATIENT wears eye glasses
PATIENT'S eyes burn or sting when waking up		PATIENT wears contact lenses
		PATIENT is interested in contact lenses

In case of emergency notify:

Contact name:

Contact phone:

Is there anything else the Doctor should know about this patient?

---

Person responsible for this patient's account:
(Entering name here is considered the same as affixing signature. Enter full, legal name.)