New Patient Form

Demographics

Title First Last MI Suffix Nickname MR. MRS. MS. DR. JUDG REV. MISS. MASTER

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
Primary Doctor	No Doctor Assigned Dr. Wilkinson, Larry Dr. Ohan, Faris Dr. Middleton, Ouida Dr. Retinal Doctors, Dr. Rx, Outside Dr. Nikoi, Naadei	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
MR. MRS. MS. DR. JUDG REV. MISS. MASTER

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

Insurance Information

Insurance Name:	None AARP GENERAL MEMBERSHIP INS AARP HEALTH CARE OPTIONS- MEDCR SUPP AARP Medicare Complete HMO - AARP Medicare Complete Access Health Advantica EyeCare Benefits - Advantica Eye Care Benefits Aetna Global Benefits - Aetna Global Benefits Aetna Health Inc - Aetna Health Inc Aetna HMO Aetna Signature Administrators PPO Aflac- NOT PROVIDERS All Savers Allied National c/o Global Care Allstate Benefits Always Care Benefits, Inc - Always Care Benefits, Inc America Choice Health, LLC American Benefit Plan Administrators American Family Life Assurance Co of Columbus American Medical and Life Insurance Company Amerigroup HMO Plan Amerigroup of Texas - Amerigroup Amerigroup Resolutions AmeriHealth Administrators Ameritas APWU Health Plan ASRM Assurant Health Avesis Incorporated Bakers Benefit Administrators- OUT OF NETWORK Bankers Life and Casualty Company Beech Street Benefit Consultants, Inc/ HL Benefit Management Administrators, Inc. Benefit Planners Benefit Services, Inc Blue Cross Blue Shield Of TX - Blue Cross Blue Shield of Texas Blue Cross Blus Shield HMO Blue Cross Medicare Advantage PPO/ HMO - Blue Cross Medicare Advantage PPO Boilermakers National Health Boon-Chapman - Boon-chapman Buffalo Service Ctr/UHC Choice Caprock Health Plans- OUT OF NETWORK Care Improvement Plus - Care Improvement Plus CareFirst Blue Cross Blue Shield of Maryland Central United Life - Central United Life Century Health CHAMPVA CIGNA-GREATWEST HEALTHCARE Cigna - Cigna Cigna Global International CIGNA Government Services Cigna Healthcare Cigna HMO- OUT OF NETWORK Cigna International Cigna Medicare Access - Cigna Medicare Access CIGNA PPO CL Frates Health Services Colonial Penn Life Insurance Company Combined Ins Co of America Community Eye Care Community Health Choice OUT OF NETWORK ConnectYourCare LLC Conneticut General Life Insurance Conseco Health-Medr Supp Constitution Life Ins Co Continental Life Insurance Company- Medcr Supp CSI Medicare Supplement Davis Vision OUT OF NETWORK Definity Health Direct Care Discount Plan Employer Plan Services Inc. - Employer Plan Services Inc. Entrust- OUT OF NETWORK!!!!! Envolve Equitable & You Express Scripts Eye Care For Kids Foundation EyeMed Vision Care Eyetopia Vision Care Family Health Life/ Medicare Supplement Farm Bureau- Texas Fidelity Security Life Insurance Company First Health Fiserv Health Services Forethought Life Insurance Company Freedom Life Insurance Company of America GE Group Administrators GEHA Genworth Life and Annuity GHI Gilsbar, Inc. Golden Rule Insurance Company Govt Personnel Mutual Life Ins Co GPA Group Administrators, Ltd. Health Assurance Health Choice Health Net Life Insurance Health Partners Claims Health Smart Benefit Solutions Health Smart/ Accel HealthSmart Preferred Care OUT OF NETWORK Helping Hands Homeland Health Care Humana Choice PPO Humana Claims- ERS Humana Claims- TRS Humana Claims Office Humana Gold Plus HMO- OUT OF NETWORK Humana One Claims Independence Administrators Insurance Management Administr International Benefits Administrators J.P. Farley Insurance - J. P. Farley J.W. Terrill Benefit Administrators Kelsey-Seybold- OUT OF NETWORK Kelsey Care Advantage- OUT OF NETWORK Liberty Mutual Insurance Life RE Insurance Co. Lifestyle Health Plans Line Construction Benefit Fund Lions Club Louisiana Laborers Health and Welfare Fund Loyal American Life Ins Co. - Medicare Suppl M. M. & P Health & Benefit Plan Manhattan Life Insurance Company MARSH MEDI- PAK Arkansas BCBS Medi-Share Medicare - Texas - Medicare - Texas Medico Insurance Company Medishare Memorial Hermann Advantage HMO- OUT OF NETWORK Memorial Hermann Health Solutions- OUT OF NETWORK Memorial Hermann Health Solutions- OUT OF NETWORK - Memorial Hermann Health Solutions Meritain Health- OUT OF NETWORK MES Vision-File Claims Online Misc. Molina Healthcare OUT OF NETWORK Monumental Life Insurance Mountain States Administrative Services Multi Plan MUTUAL OF OMAHA MVP Health Care National Association of Letter Carriers Health Benefit Plan National States Insurance Company National Vision Administrators Nationwide Specialty Health New Era Life Insurance Company New Insurance New Insurance Nippon Life Benefits No Insurance NO SUPPLEMENT Old Surety Life Insurance Company One Health Plan Opticare Pacificare Life And Health Ins PacifiCare Life Assurance Company PHCS Philadelphia American Life Insurance Company- Supplement Physicians Mutual Insurance Company Physicians Mutual Life Ins Pipeline Insdustry Benefit Fund Plumbers Local 68 Premier Eye Care Principal Life Insurance Company- email claims Pyramid Life Insurance Railroad Medicare - Railroad Medicare Reliance Standard Reserved National Insurane Co. - Reserved National Insurance Co Retired Medical Insurance ROJW- Health Care Support Royal Neighbors of America Rural Carrier Benefit Plan SafeGuard Seabury & Smith Secure Horizons Of Texas Sentinel Security Life Insurance Company Sisco Southern Operators Health Fund Southwest Advantra Southwest Service Life Standard Life and Accident Ins Co Starmark State Farm Health Insurance Sterling Investors Life Ins Co. Sterling Life Insurance Company Strategic Resource Company Student Resources/UHC SunLife Financial Insurance Superior Vision Of Texas, Inc - Superior Vision of Texas, Inc Superior Vision Services Inc. Texan Plus HMO Plan OUT OF NETWORK Texas HealthSpring OUT OF NETWORK Texas Mutual Insurance Company TML TransAmerica Premier Life Insurance Co. Tri-Care for Life OUT OF NETWORK TX Medicaid & Healthcare Prtsp - Texas Medicaid & Heathcare Prtsp UHC Community Plan Dual Complete HMO UHC VISION UMWA Health & Retirement Fund United American United Healthcare - United Healthcare United Healthcare HMO- OUT OF NETWORK United Healthcare Shared Services - United Healthcare Shared Services United Medical Resources, Inc. United Teacher Assc Insurance United World Life Ins- Medicare Supplement Universal Fidelity Universal Healthcare Insurance - Universal Healthcare Insurance US FAMILY HEALTH PLAN USAA USAA LIFE INSURANCE COMPANY VBA VCP/ HUMANA Vision USA VSP - Vision Service Plan Vsp Access WellCare- OUT OF NETWORK!!!! WellNet Wells Fargo Third Party Admin Woodmen of the World- Medicare Supplement Zenith American Solutions
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

Insurance Information

Insurance Name:	None AARP GENERAL MEMBERSHIP INS AARP HEALTH CARE OPTIONS- MEDCR SUPP AARP Medicare Complete HMO - AARP Medicare Complete Access Health Advantica EyeCare Benefits - Advantica Eye Care Benefits Aetna Global Benefits - Aetna Global Benefits Aetna Health Inc - Aetna Health Inc Aetna HMO Aetna Signature Administrators PPO Aflac- NOT PROVIDERS All Savers Allied National c/o Global Care Allstate Benefits Always Care Benefits, Inc - Always Care Benefits, Inc America Choice Health, LLC American Benefit Plan Administrators American Family Life Assurance Co of Columbus American Medical and Life Insurance Company Amerigroup HMO Plan Amerigroup of Texas - Amerigroup Amerigroup Resolutions AmeriHealth Administrators Ameritas APWU Health Plan ASRM Assurant Health Avesis Incorporated Bakers Benefit Administrators- OUT OF NETWORK Bankers Life and Casualty Company Beech Street Benefit Consultants, Inc/ HL Benefit Management Administrators, Inc. Benefit Planners Benefit Services, Inc Blue Cross Blue Shield Of TX - Blue Cross Blue Shield of Texas Blue Cross Blus Shield HMO Blue Cross Medicare Advantage PPO/ HMO - Blue Cross Medicare Advantage PPO Boilermakers National Health Boon-Chapman - Boon-chapman Buffalo Service Ctr/UHC Choice Caprock Health Plans- OUT OF NETWORK Care Improvement Plus - Care Improvement Plus CareFirst Blue Cross Blue Shield of Maryland Central United Life - Central United Life Century Health CHAMPVA CIGNA-GREATWEST HEALTHCARE Cigna - Cigna Cigna Global International CIGNA Government Services Cigna Healthcare Cigna HMO- OUT OF NETWORK Cigna International Cigna Medicare Access - Cigna Medicare Access CIGNA PPO CL Frates Health Services Colonial Penn Life Insurance Company Combined Ins Co of America Community Eye Care Community Health Choice OUT OF NETWORK ConnectYourCare LLC Conneticut General Life Insurance Conseco Health-Medr Supp Constitution Life Ins Co Continental Life Insurance Company- Medcr Supp CSI Medicare Supplement Davis Vision OUT OF NETWORK Definity Health Direct Care Discount Plan Employer Plan Services Inc. - Employer Plan Services Inc. Entrust- OUT OF NETWORK!!!!! Envolve Equitable & You Express Scripts Eye Care For Kids Foundation EyeMed Vision Care Eyetopia Vision Care Family Health Life/ Medicare Supplement Farm Bureau- Texas Fidelity Security Life Insurance Company First Health Fiserv Health Services Forethought Life Insurance Company Freedom Life Insurance Company of America GE Group Administrators GEHA Genworth Life and Annuity GHI Gilsbar, Inc. Golden Rule Insurance Company Govt Personnel Mutual Life Ins Co GPA Group Administrators, Ltd. Health Assurance Health Choice Health Net Life Insurance Health Partners Claims Health Smart Benefit Solutions Health Smart/ Accel HealthSmart Preferred Care OUT OF NETWORK Helping Hands Homeland Health Care Humana Choice PPO Humana Claims- ERS Humana Claims- TRS Humana Claims Office Humana Gold Plus HMO- OUT OF NETWORK Humana One Claims Independence Administrators Insurance Management Administr International Benefits Administrators J.P. Farley Insurance - J. P. Farley J.W. Terrill Benefit Administrators Kelsey-Seybold- OUT OF NETWORK Kelsey Care Advantage- OUT OF NETWORK Liberty Mutual Insurance Life RE Insurance Co. Lifestyle Health Plans Line Construction Benefit Fund Lions Club Louisiana Laborers Health and Welfare Fund Loyal American Life Ins Co. - Medicare Suppl M. M. & P Health & Benefit Plan Manhattan Life Insurance Company MARSH MEDI- PAK Arkansas BCBS Medi-Share Medicare - Texas - Medicare - Texas Medico Insurance Company Medishare Memorial Hermann Advantage HMO- OUT OF NETWORK Memorial Hermann Health Solutions- OUT OF NETWORK Memorial Hermann Health Solutions- OUT OF NETWORK - Memorial Hermann Health Solutions Meritain Health- OUT OF NETWORK MES Vision-File Claims Online Misc. Molina Healthcare OUT OF NETWORK Monumental Life Insurance Mountain States Administrative Services Multi Plan MUTUAL OF OMAHA MVP Health Care National Association of Letter Carriers Health Benefit Plan National States Insurance Company National Vision Administrators Nationwide Specialty Health New Era Life Insurance Company New Insurance New Insurance Nippon Life Benefits No Insurance NO SUPPLEMENT Old Surety Life Insurance Company One Health Plan Opticare Pacificare Life And Health Ins PacifiCare Life Assurance Company PHCS Philadelphia American Life Insurance Company- Supplement Physicians Mutual Insurance Company Physicians Mutual Life Ins Pipeline Insdustry Benefit Fund Plumbers Local 68 Premier Eye Care Principal Life Insurance Company- email claims Pyramid Life Insurance Railroad Medicare - Railroad Medicare Reliance Standard Reserved National Insurane Co. - Reserved National Insurance Co Retired Medical Insurance ROJW- Health Care Support Royal Neighbors of America Rural Carrier Benefit Plan SafeGuard Seabury & Smith Secure Horizons Of Texas Sentinel Security Life Insurance Company Sisco Southern Operators Health Fund Southwest Advantra Southwest Service Life Standard Life and Accident Ins Co Starmark State Farm Health Insurance Sterling Investors Life Ins Co. Sterling Life Insurance Company Strategic Resource Company Student Resources/UHC SunLife Financial Insurance Superior Vision Of Texas, Inc - Superior Vision of Texas, Inc Superior Vision Services Inc. Texan Plus HMO Plan OUT OF NETWORK Texas HealthSpring OUT OF NETWORK Texas Mutual Insurance Company TML TransAmerica Premier Life Insurance Co. Tri-Care for Life OUT OF NETWORK TX Medicaid & Healthcare Prtsp - Texas Medicaid & Heathcare Prtsp UHC Community Plan Dual Complete HMO UHC VISION UMWA Health & Retirement Fund United American United Healthcare - United Healthcare United Healthcare HMO- OUT OF NETWORK United Healthcare Shared Services - United Healthcare Shared Services United Medical Resources, Inc. United Teacher Assc Insurance United World Life Ins- Medicare Supplement Universal Fidelity Universal Healthcare Insurance - Universal Healthcare Insurance US FAMILY HEALTH PLAN USAA USAA LIFE INSURANCE COMPANY VBA VCP/ HUMANA Vision USA VSP - Vision Service Plan Vsp Access WellCare- OUT OF NETWORK!!!! WellNet Wells Fargo Third Party Admin Woodmen of the World- Medicare Supplement Zenith American Solutions
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

Insurance Information

Insurance Name:	None AARP GENERAL MEMBERSHIP INS AARP HEALTH CARE OPTIONS- MEDCR SUPP AARP Medicare Complete HMO - AARP Medicare Complete Access Health Advantica EyeCare Benefits - Advantica Eye Care Benefits Aetna Global Benefits - Aetna Global Benefits Aetna Health Inc - Aetna Health Inc Aetna HMO Aetna Signature Administrators PPO Aflac- NOT PROVIDERS All Savers Allied National c/o Global Care Allstate Benefits Always Care Benefits, Inc - Always Care Benefits, Inc America Choice Health, LLC American Benefit Plan Administrators American Family Life Assurance Co of Columbus American Medical and Life Insurance Company Amerigroup HMO Plan Amerigroup of Texas - Amerigroup Amerigroup Resolutions AmeriHealth Administrators Ameritas APWU Health Plan ASRM Assurant Health Avesis Incorporated Bakers Benefit Administrators- OUT OF NETWORK Bankers Life and Casualty Company Beech Street Benefit Consultants, Inc/ HL Benefit Management Administrators, Inc. Benefit Planners Benefit Services, Inc Blue Cross Blue Shield Of TX - Blue Cross Blue Shield of Texas Blue Cross Blus Shield HMO Blue Cross Medicare Advantage PPO/ HMO - Blue Cross Medicare Advantage PPO Boilermakers National Health Boon-Chapman - Boon-chapman Buffalo Service Ctr/UHC Choice Caprock Health Plans- OUT OF NETWORK Care Improvement Plus - Care Improvement Plus CareFirst Blue Cross Blue Shield of Maryland Central United Life - Central United Life Century Health CHAMPVA CIGNA-GREATWEST HEALTHCARE Cigna - Cigna Cigna Global International CIGNA Government Services Cigna Healthcare Cigna HMO- OUT OF NETWORK Cigna International Cigna Medicare Access - Cigna Medicare Access CIGNA PPO CL Frates Health Services Colonial Penn Life Insurance Company Combined Ins Co of America Community Eye Care Community Health Choice OUT OF NETWORK ConnectYourCare LLC Conneticut General Life Insurance Conseco Health-Medr Supp Constitution Life Ins Co Continental Life Insurance Company- Medcr Supp CSI Medicare Supplement Davis Vision OUT OF NETWORK Definity Health Direct Care Discount Plan Employer Plan Services Inc. - Employer Plan Services Inc. Entrust- OUT OF NETWORK!!!!! Envolve Equitable & You Express Scripts Eye Care For Kids Foundation EyeMed Vision Care Eyetopia Vision Care Family Health Life/ Medicare Supplement Farm Bureau- Texas Fidelity Security Life Insurance Company First Health Fiserv Health Services Forethought Life Insurance Company Freedom Life Insurance Company of America GE Group Administrators GEHA Genworth Life and Annuity GHI Gilsbar, Inc. Golden Rule Insurance Company Govt Personnel Mutual Life Ins Co GPA Group Administrators, Ltd. Health Assurance Health Choice Health Net Life Insurance Health Partners Claims Health Smart Benefit Solutions Health Smart/ Accel HealthSmart Preferred Care OUT OF NETWORK Helping Hands Homeland Health Care Humana Choice PPO Humana Claims- ERS Humana Claims- TRS Humana Claims Office Humana Gold Plus HMO- OUT OF NETWORK Humana One Claims Independence Administrators Insurance Management Administr International Benefits Administrators J.P. Farley Insurance - J. P. Farley J.W. Terrill Benefit Administrators Kelsey-Seybold- OUT OF NETWORK Kelsey Care Advantage- OUT OF NETWORK Liberty Mutual Insurance Life RE Insurance Co. Lifestyle Health Plans Line Construction Benefit Fund Lions Club Louisiana Laborers Health and Welfare Fund Loyal American Life Ins Co. - Medicare Suppl M. M. & P Health & Benefit Plan Manhattan Life Insurance Company MARSH MEDI- PAK Arkansas BCBS Medi-Share Medicare - Texas - Medicare - Texas Medico Insurance Company Medishare Memorial Hermann Advantage HMO- OUT OF NETWORK Memorial Hermann Health Solutions- OUT OF NETWORK Memorial Hermann Health Solutions- OUT OF NETWORK - Memorial Hermann Health Solutions Meritain Health- OUT OF NETWORK MES Vision-File Claims Online Misc. Molina Healthcare OUT OF NETWORK Monumental Life Insurance Mountain States Administrative Services Multi Plan MUTUAL OF OMAHA MVP Health Care National Association of Letter Carriers Health Benefit Plan National States Insurance Company National Vision Administrators Nationwide Specialty Health New Era Life Insurance Company New Insurance New Insurance Nippon Life Benefits No Insurance NO SUPPLEMENT Old Surety Life Insurance Company One Health Plan Opticare Pacificare Life And Health Ins PacifiCare Life Assurance Company PHCS Philadelphia American Life Insurance Company- Supplement Physicians Mutual Insurance Company Physicians Mutual Life Ins Pipeline Insdustry Benefit Fund Plumbers Local 68 Premier Eye Care Principal Life Insurance Company- email claims Pyramid Life Insurance Railroad Medicare - Railroad Medicare Reliance Standard Reserved National Insurane Co. - Reserved National Insurance Co Retired Medical Insurance ROJW- Health Care Support Royal Neighbors of America Rural Carrier Benefit Plan SafeGuard Seabury & Smith Secure Horizons Of Texas Sentinel Security Life Insurance Company Sisco Southern Operators Health Fund Southwest Advantra Southwest Service Life Standard Life and Accident Ins Co Starmark State Farm Health Insurance Sterling Investors Life Ins Co. Sterling Life Insurance Company Strategic Resource Company Student Resources/UHC SunLife Financial Insurance Superior Vision Of Texas, Inc - Superior Vision of Texas, Inc Superior Vision Services Inc. Texan Plus HMO Plan OUT OF NETWORK Texas HealthSpring OUT OF NETWORK Texas Mutual Insurance Company TML TransAmerica Premier Life Insurance Co. Tri-Care for Life OUT OF NETWORK TX Medicaid & Healthcare Prtsp - Texas Medicaid & Heathcare Prtsp UHC Community Plan Dual Complete HMO UHC VISION UMWA Health & Retirement Fund United American United Healthcare - United Healthcare United Healthcare HMO- OUT OF NETWORK United Healthcare Shared Services - United Healthcare Shared Services United Medical Resources, Inc. United Teacher Assc Insurance United World Life Ins- Medicare Supplement Universal Fidelity Universal Healthcare Insurance - Universal Healthcare Insurance US FAMILY HEALTH PLAN USAA USAA LIFE INSURANCE COMPANY VBA VCP/ HUMANA Vision USA VSP - Vision Service Plan Vsp Access WellCare- OUT OF NETWORK!!!! WellNet Wells Fargo Third Party Admin Woodmen of the World- Medicare Supplement Zenith American Solutions
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:

Fourtiary Insurance

Insurance Information

Insurance Name:	None AARP GENERAL MEMBERSHIP INS AARP HEALTH CARE OPTIONS- MEDCR SUPP AARP Medicare Complete HMO - AARP Medicare Complete Access Health Advantica EyeCare Benefits - Advantica Eye Care Benefits Aetna Global Benefits - Aetna Global Benefits Aetna Health Inc - Aetna Health Inc Aetna HMO Aetna Signature Administrators PPO Aflac- NOT PROVIDERS All Savers Allied National c/o Global Care Allstate Benefits Always Care Benefits, Inc - Always Care Benefits, Inc America Choice Health, LLC American Benefit Plan Administrators American Family Life Assurance Co of Columbus American Medical and Life Insurance Company Amerigroup HMO Plan Amerigroup of Texas - Amerigroup Amerigroup Resolutions AmeriHealth Administrators Ameritas APWU Health Plan ASRM Assurant Health Avesis Incorporated Bakers Benefit Administrators- OUT OF NETWORK Bankers Life and Casualty Company Beech Street Benefit Consultants, Inc/ HL Benefit Management Administrators, Inc. Benefit Planners Benefit Services, Inc Blue Cross Blue Shield Of TX - Blue Cross Blue Shield of Texas Blue Cross Blus Shield HMO Blue Cross Medicare Advantage PPO/ HMO - Blue Cross Medicare Advantage PPO Boilermakers National Health Boon-Chapman - Boon-chapman Buffalo Service Ctr/UHC Choice Caprock Health Plans- OUT OF NETWORK Care Improvement Plus - Care Improvement Plus CareFirst Blue Cross Blue Shield of Maryland Central United Life - Central United Life Century Health CHAMPVA CIGNA-GREATWEST HEALTHCARE Cigna - Cigna Cigna Global International CIGNA Government Services Cigna Healthcare Cigna HMO- OUT OF NETWORK Cigna International Cigna Medicare Access - Cigna Medicare Access CIGNA PPO CL Frates Health Services Colonial Penn Life Insurance Company Combined Ins Co of America Community Eye Care Community Health Choice OUT OF NETWORK ConnectYourCare LLC Conneticut General Life Insurance Conseco Health-Medr Supp Constitution Life Ins Co Continental Life Insurance Company- Medcr Supp CSI Medicare Supplement Davis Vision OUT OF NETWORK Definity Health Direct Care Discount Plan Employer Plan Services Inc. - Employer Plan Services Inc. Entrust- OUT OF NETWORK!!!!! Envolve Equitable & You Express Scripts Eye Care For Kids Foundation EyeMed Vision Care Eyetopia Vision Care Family Health Life/ Medicare Supplement Farm Bureau- Texas Fidelity Security Life Insurance Company First Health Fiserv Health Services Forethought Life Insurance Company Freedom Life Insurance Company of America GE Group Administrators GEHA Genworth Life and Annuity GHI Gilsbar, Inc. Golden Rule Insurance Company Govt Personnel Mutual Life Ins Co GPA Group Administrators, Ltd. Health Assurance Health Choice Health Net Life Insurance Health Partners Claims Health Smart Benefit Solutions Health Smart/ Accel HealthSmart Preferred Care OUT OF NETWORK Helping Hands Homeland Health Care Humana Choice PPO Humana Claims- ERS Humana Claims- TRS Humana Claims Office Humana Gold Plus HMO- OUT OF NETWORK Humana One Claims Independence Administrators Insurance Management Administr International Benefits Administrators J.P. Farley Insurance - J. P. Farley J.W. Terrill Benefit Administrators Kelsey-Seybold- OUT OF NETWORK Kelsey Care Advantage- OUT OF NETWORK Liberty Mutual Insurance Life RE Insurance Co. Lifestyle Health Plans Line Construction Benefit Fund Lions Club Louisiana Laborers Health and Welfare Fund Loyal American Life Ins Co. - Medicare Suppl M. M. & P Health & Benefit Plan Manhattan Life Insurance Company MARSH MEDI- PAK Arkansas BCBS Medi-Share Medicare - Texas - Medicare - Texas Medico Insurance Company Medishare Memorial Hermann Advantage HMO- OUT OF NETWORK Memorial Hermann Health Solutions- OUT OF NETWORK Memorial Hermann Health Solutions- OUT OF NETWORK - Memorial Hermann Health Solutions Meritain Health- OUT OF NETWORK MES Vision-File Claims Online Misc. Molina Healthcare OUT OF NETWORK Monumental Life Insurance Mountain States Administrative Services Multi Plan MUTUAL OF OMAHA MVP Health Care National Association of Letter Carriers Health Benefit Plan National States Insurance Company National Vision Administrators Nationwide Specialty Health New Era Life Insurance Company New Insurance New Insurance Nippon Life Benefits No Insurance NO SUPPLEMENT Old Surety Life Insurance Company One Health Plan Opticare Pacificare Life And Health Ins PacifiCare Life Assurance Company PHCS Philadelphia American Life Insurance Company- Supplement Physicians Mutual Insurance Company Physicians Mutual Life Ins Pipeline Insdustry Benefit Fund Plumbers Local 68 Premier Eye Care Principal Life Insurance Company- email claims Pyramid Life Insurance Railroad Medicare - Railroad Medicare Reliance Standard Reserved National Insurane Co. - Reserved National Insurance Co Retired Medical Insurance ROJW- Health Care Support Royal Neighbors of America Rural Carrier Benefit Plan SafeGuard Seabury & Smith Secure Horizons Of Texas Sentinel Security Life Insurance Company Sisco Southern Operators Health Fund Southwest Advantra Southwest Service Life Standard Life and Accident Ins Co Starmark State Farm Health Insurance Sterling Investors Life Ins Co. Sterling Life Insurance Company Strategic Resource Company Student Resources/UHC SunLife Financial Insurance Superior Vision Of Texas, Inc - Superior Vision of Texas, Inc Superior Vision Services Inc. Texan Plus HMO Plan OUT OF NETWORK Texas HealthSpring OUT OF NETWORK Texas Mutual Insurance Company TML TransAmerica Premier Life Insurance Co. Tri-Care for Life OUT OF NETWORK TX Medicaid & Healthcare Prtsp - Texas Medicaid & Heathcare Prtsp UHC Community Plan Dual Complete HMO UHC VISION UMWA Health & Retirement Fund United American United Healthcare - United Healthcare United Healthcare HMO- OUT OF NETWORK United Healthcare Shared Services - United Healthcare Shared Services United Medical Resources, Inc. United Teacher Assc Insurance United World Life Ins- Medicare Supplement Universal Fidelity Universal Healthcare Insurance - Universal Healthcare Insurance US FAMILY HEALTH PLAN USAA USAA LIFE INSURANCE COMPANY VBA VCP/ HUMANA Vision USA VSP - Vision Service Plan Vsp Access WellCare- OUT OF NETWORK!!!! WellNet Wells Fargo Third Party Admin Woodmen of the World- Medicare Supplement Zenith American Solutions
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

Patients medication

On Patient History None Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonix Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracycline Levaquin Plaquenil PRENATAL VITAMINS Other

med2

Glyburide Hydrocorisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Premarin Synthroid Amiodarone Atenolol Captopril Clonidin Furosamide Lasix HCTZ Zestril ALtase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepcid Zantac Protonis Detrol Flomax Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Dpakote Topamax Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracyclin Levaquin Plaquenil Other

med3

Premarin Synthroid Amiodarone Atenlol Captopril Furosamide Lasix HCTZ Zestril Altase Cozar Crestor Diovan Lipitor Albuterol Allegra Flonase Nasacort Singular Proventil Pepecid Xantac Protonix Flomax Detrol Xanax Wellbutrin Buspar Valium Prozac Ritalin Adderall Effexor Zoloft Diclofenac Lortab MS Contin Oxycodone Celebrex Carbamazepine Depakote Topamax Dilantin Coumadin Plavix Bactroban Cipro Acyclovir Cefzil Amoxycillin Augmentin Tetracyclin Levaquin Plaquenil Glyburide Hydrocortisone Glucophage Metformin Methlyprednisolone Prednisone Actos Amaryl Humulin Novalog Prempro Other

Drug Allergies:

NKDA Codeine Penicillin Sulfa Other

PATIENT MEDICAL HISTORY: HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid

Good health Arthritis Asthma Diabetes HBP Headaches Heart Condition HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Smoking Seizure Disorder Cholestral Thyroid Disease Preg "Now" Nursing Diagnosed As HIV+ ADHD Other

medhx3

Athritis Diabetes HBP Heart Disease Cancer Lupus Kidney Disease Thyroid Disease Back Problems Other

medhx2

Diabetes HBP Heart disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other

medhx4

Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Back Problems Other

medhx5

Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Thyroid Disease Back Problems Other

medhx6

Diabetes HBP Heart Disease Cancer Arthritis Lupus Kidney Disease Thyroid Back Problems Other

Injuries, Surgeries, Hospitalization

Pregnant Or Nursing:

No Yes Unsure Other

FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other

None Adopted Diabetes HBP Cancer Cardiovascular Disease Athritis Kidney Disease Lupus Thyroid Other

fmh2

fmh3

Occupation:

student Other

Notes:

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

Review Of Systems

GENERAL: Fever, weight loss, weight gain, fatigue?

None Fever Weight Loss Weight Gain Fatigue Other

EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat

None Allergies Sinus Problems Chronic Cough Dry Throat / Mouth Hard of Hearing Other

CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease

None High BP Surgery Vascular Disease Other

RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD

None Asthma Bronchitis Emphysema COPD Other

GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence

None painful urination frequent urination impotence yellow jaundice Other

MUSCLES, BONES, JOINTS: Athritis, Joint Pains, Head or Neck Injury

None joint pain stiffness swelling cramps arthritis Other

SKIN: growths, rashes, acne

None pimples, warts growths rash Other

NEUROLOGICAL: Headaches, migraines, seizures

None numbness, paralysis headache seizures migraines Other

PSYCHIATRIC: Depression, Anxiety, Insomnia

None anxiety depression insomnia Other

ENDORCRINE: Thyroid, Diabetes

None diabetes hypothyroid hyperthoyroid Other

BLOOD/LYMPH: Anemia, cholesterol, bleeding problems

None bleeding cholestrolemia anemia Other

ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus

None sneezing swelling redness itching hives lupus Other

GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

None Diarrhea Constipation Ulcer Acid Reflux Other

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