Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Miss 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:		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

Is the Billing Address Different?

Billing Information

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

Copy Address From Above
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:

By checking this box I agree to all the terms listed below. FOR ALL NO CALL/NO SHOW'S A $25 CANELLATION FEE WILL BE CHARGED TO YOUR ACCOUNT THAT MUST BE PAID PRIOR TO ANY FURTHER APPOINTMENTS BEING MADE. THIS FEE IS NONREFUNDABLE AND CANNOT BE APPLIED TO ANY SERVICES OR MATERIALS. I request payment of authorized benefits be made to Coast Eyes PLLC. I authorize any holder of medical information about me to release such to the health care financing administration and its agents to determine benefits. I hereby assign payment to Coast Eyes PLLC for expenses relative to services and/or materials provided. I understand ALL conditions of coverage and agreements are between the patient and insurance company and Coast Eyes Pllc has no authority concerning insurance coverage. I accept personal liability for any/all outstanding indebtedness determined by my insurance coverage and/or non-covered services. I understand Coast Eyes PLLC reserves the right to charge a $5 statement fee for each statement after the primary statement and that it is my responsibility to provide a correct and current address, phone number and email for correspondence. I accept responsibility to coordinate my primary and secondary benefits and accept liability for any expenses not covered as a result of any lack of coordination. Coast Eyes PLLC is not responsible for filing secondary claims and any unpaid secondary balances may be billed to the patient. I agree to pay the maximum bounced check fee allowed per Mississippi Law ($40) in addition to the initial debt should I write a check with insufficient funds. I authorize the release of information contained in my medical record to my insurance company and health care providers for the purpose of patient care. I consent for any/all clinical tests to be performed that are deemed medically necessary by the providers of Coast Eyes PLLC. I understand that a copy of my HIPPA privacy rights are available for review. I understand glasses are a custom product and there are NO refunds for used frames or lenses once fabrication has begun nor refunds for buyers remorse. All frame warranties are for manufacturer's defects (not breakage or abuse) and are given at the discretion of the manufacturer, not Coast Eyes Pllc. A restocking fee of $5/box will be charged for all contact lens box returns. I agree to Coast Eyes contacting me by using any information provided on this form for anything deemed necessary related to our relationship. I accept responsibility for any indebtedness for any person under 21 I am listed responsible for. Services, materials, records or prescriptions will not be provided to anyone with a balance.

Medical

Primary Medical Insurance Information

Insurance Name:	None AARP Health Care Options Acs Medicaid Advantica Eye Care AETNA AlwaysCare Benefits, Inc Assurant Healthcare Blue Cross Blue Shield Blue Shield CBA Century Healthcare, LLC Champ VA Cigna Health Care Cigna International Comp Benefits Continental Benefits Coventry Davis Vision Dmerc/Cigna Government Services Emblem Health Envolve EyeMed FCE Benefits FMH CoreSource Fox Everett GEHA General Insurance Golden Rule Insurance Company GWH-CIGNA Health Spring Humana HUMANA VISION ITPEU HEALTH & WELFARE FUND Laborer's National H&W Fund Lockard & Williams LUBA Worker's Comp MAIL HANDLERS BENEFIT PLAN March Vision Medicare Part B Meritain Health MHP Systems Mississippi Physicians Care Network Monumental Life Insurance MPE Employee Benefit Servies Mutual of Omaha Pittman & Associates PPOplus, LLC Private Pay Railroad Retire Beneficeries Rural Carrier Benefit Plan Select Admin. Services State Farm Health Insurance Sterling Investors Life Insurance Tricare for Life Tricare Prime Tricare Select(Standard)/Reserve Select UMR United HealthCare VSP
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 Health Care Options Acs Medicaid Advantica Eye Care AETNA AlwaysCare Benefits, Inc Assurant Healthcare Blue Cross Blue Shield Blue Shield CBA Century Healthcare, LLC Champ VA Cigna Health Care Cigna International Comp Benefits Continental Benefits Coventry Davis Vision Dmerc/Cigna Government Services Emblem Health Envolve EyeMed FCE Benefits FMH CoreSource Fox Everett GEHA General Insurance Golden Rule Insurance Company GWH-CIGNA Health Spring Humana HUMANA VISION ITPEU HEALTH & WELFARE FUND Laborer's National H&W Fund Lockard & Williams LUBA Worker's Comp MAIL HANDLERS BENEFIT PLAN March Vision Medicare Part B Meritain Health MHP Systems Mississippi Physicians Care Network Monumental Life Insurance MPE Employee Benefit Servies Mutual of Omaha Pittman & Associates PPOplus, LLC Private Pay Railroad Retire Beneficeries Rural Carrier Benefit Plan Select Admin. Services State Farm Health Insurance Sterling Investors Life Insurance Tricare for Life Tricare Prime Tricare Select(Standard)/Reserve Select UMR United HealthCare VSP
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:

Vision

Insurance Information

Insurance Name:	None AARP Health Care Options Acs Medicaid Advantica Eye Care AETNA AlwaysCare Benefits, Inc Assurant Healthcare Blue Cross Blue Shield Blue Shield CBA CDHP Century Healthcare, LLC Champ VA Cigna Health Care Cigna International Comp Benefits Continental Benefits Coventry Davis Vision Dmerc/Cigna Government Services Emblem Health EyeMed FCE Benefits FMH CoreSource Fox Everett GEHA General Insurance Golden Rule Insurance Company GWH-CIGNA GWH-CIGNA Health Spring Humana HUMANA VISION ITPEU HEALTH & WELFARE FUND Laborer's National H&W Fund Lockard & Williams LUBA Worker's Comp Magnolia Health Plan MAIL HANDLERS BENEFIT PLAN March Vision Medicare Part B Meritain Health MHP Systems Mid-West National Life Insurance Co Mississippi Physicians Care Network Monumental Life Insurance MPE Employee Benefit Servies Mutual of Omaha OptiCare Managed Vision Pittman & Associates PPOplus, LLC Railroad Retire Beneficeries Rural Carrier Benefit Plan Select Admin. Services State Farm Health Insurance Sterling Investors Life Insurance Strategic Comp Tricare for Life Tricare Prime Tricare Standard/Reserve Select UMR United HealthCare United Medical Resources, Inc. VSP Washington National Insurance Company z
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

Visual History

Last Eye Exam

1 year 2 years 3 years Other

Please check ALL that apply to your eyes:

Decrease in Vision	Eye Pain
Excess Tearing/Watery	Dry Eyes
Itching	Glare
Redness	Stye
Flashes of Light	Floaters
Headaches

Please list any eye diseases/injuries you're experiencing:

What contact lenses do you currently use?:

*if applicable

Check areas of interest:

New Glasses

New/Updated Contact Lens Prescription

Bifocal Contact Lenses

Colored Contact Lenses

Prescription Sunglasses

Computer Bifocals

Other:

Past, Current and Family History of Eye Conditions

	You	Family	No
Cataract
Blindness
Glaucoma
Retinal Detachment
Macular Degeneration
Retinitis Pigmentosa

Please describe any other history of eye disease:

Please describe any other family history of eye disease:

Medical History (problems with bodily systems)

	You	Family	No
Diabetes
Gastrointestinal
Ear/Nose/Throat
Cardiovascular
Respiratory
High BP
Nervous System
Genitourinary
Musculoskeletal
Mental System
Endocrine
Blood/Lymph
Allergy/Immune
Allergies
Medication Use

Please list your current medications:

Please list any medications you are allergic to:

Pregnant Or Nursing?:

No Yes Unsure Other

Social History

Smoking Status:	Never smoker (<100 cigs equiv) 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
Alcohol Use:	No Yes Occasionally Socially Other

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