Online Patient Forms

Patient Information

Upload Driver Lisc [front]:

Front of the card preview

First Name

*This field is required

Last Name

*This field is required

Birth Sex

Male Female

Address

Apt/Suite #

City

State

Zip Code

Cell Phone

*This field is required

Home Phone

Preferred Contact Method

Birthday

Last 4 of SSN

Occupation

Marital Status

Misc/Guardian

Vision Care Plan vs Medical Insurance

Vision care plans are designed for routine eye care services, such as annual exams, glasses, and contact lenses, for individuals with healthy eyes. If you have a pre-existing medical conditions or require medically necessary treatment, a vision care plan wil NOT cover medical services.

Medical insurance will cover pre-existing conditions or medically necessary treatments, including conditions such as diabetes, infections, allergies, dry eyes, cataracts, and other eye health issues. Medical offices must file claims through medical insurance for these conditions. Submitting medical claims through a vision plan is considered fraudulent and violates healthcare regulations.

I understand the difference between a vision care plan and medical insurance. I accept that Master Eye Associates will ensure accurate billing practices in full compliance with healthcare regulations.

Things To Know Before Your Visit

Our annual comprehensive eye exams include retinal imaging to assess your ocular health. This may be covered by your vision care plan, insurance, or cost up to $39 depending on your copay.

Initial

Primary Medical Insurance

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

Insurance Name:

Insurance ID:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Relationship Options:

Spouse Child Other

Birth Sex:

Male Female

Birthday:

Last 4 of SSN:

Primary Vision Insurance

Insurance Information

Front of the ins card:
Front of the card preview

Back of the ins card:
Back of the card preview

Insurance Name:

Insurance ID:

Not Primary On Account:

Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Birthday:

Last 4 of SSN:

Please choose from the menu options or select the option to type in your own text. Thank you!

Reason For Visit

Vision Complaint

Medical Complaint

Eye History

Primary Vision Correction

Types of Contacts Worn

Do you currently have a history of any of the following?

Have you had any eye surgeries?

Personal Medical History

None, I'm Healthy

General

Skin

Ear/Nose/Throat

Respiratory

Musculoskeletal

Psychiatric

Endocrine

Blood/Lymph

Neurological

Immune

Genitourinary

Gastrointestinal

Cardiovascular

Cancer

Other

Current Medications No Medications

Drug Allergies No Known Drug Allergies

Do you have Diabetes?

Yes

Diabetic Exam Questions

Type of diabetes

Year Diabetes diagnosed

Last RBS

Last HbA1C

Current Therapy

How well controlled?

Who manages conditions?

Social History

Smoking Status

Do you drink Alcohol?

Do you use Recreational Drugs?

Family Medical History

Does anyone in your family have any medical conditions?

Family Eye History

Does anyone in your family have any eye conditions?

Office Policies Agreement

Please review the following agreement. Sign below to acknowledge and attach your signature to the final PDF.

Please ADD the above numbers together.