Demographics

Patient Information

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

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		Drivers License #

Is the Billing Address Different?

Billing Information

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

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:

Primary Medical

Insurance Information

Insurance Name:	None AARP Accident Fund Administrative Concepts, Inc. Advantica Benefit Aetna Aetna-American Continental Ins. Co. Aflac All Savers Alliance Health and life ins. co. Allstate American Heritage Life Ins. Co Always Care Anchor Claims Management Assurant Health Avesis Insurance Inc. AXIS-CR England Insurance Best Life and Health Insurance Company Block Vision of Texas, Inc. Blue Cross Blue Shield Boone-Chapman Benefit Administrators, In Bunch and Associates Care N Care CDS Group Health CHAMPVA ChoiceCare Network Christian Brothers Employee Benefit Trus Cigna Cigna - APWU Cincinnati Insurance Company Coast to Coast Collections CoreSource COSE Medical Mutual Coventry Health Care, Inc. Crime Victim Services Davis Vision Deseret Mutual DO NOT USE XXX AARP Medicare UHC DO NOT USE XXX Anthem Blue Cross DO NOT USE XXX BCBS Medicare Advantage DO NOT USE XXX BCBS of Arkansas DO NOT USE XXX BCBS of Kansas City DO NOT USE XXX BCBS of Louisiana DO NOT USE XXX BCBS of Michigan DO NOT USE XXX BCBS of Mississippi DO NOT USE XXX BCBS of Nebraska DO NOT USE XXX BCBS of North Carolina DO NOT USE XXX CIGNA HealthCare DO NOT USE XXX CIGNA International DO NOT USE XXX UHC - Micare Complete DO NOT USE XXX UHC Mcare Solutions Envolve Vision of Texas/OptiCareManaged Eyemed Vision Care First Health Freedom Life Insurance Co.of America Gallagher Basset GEHA GPA Group Resources Guarantee Trust Life ins. GWH-Cigna Open Access Plus GWH-Cigna PPO Hanover Insurance HealthAmerica HealthComp HealthLink Open Access HealthSCOPE HealthSmart Preferred Care Hometown Health Humana Humana One Humana/Vision Comp Benefits IMG Kaiser Permanente Ins. Co. Keller Foundations 1130 Liberty Healthshare Liberty Mutual Lifestyle Health Plans Manhattan Life Insurance Company Medcost Preferred Medi-Share Medica Medicare Medicare Complete Medipac Assistance International Inc. Meritan Health MES Vision Met Life Claims MHBP Mutual of Omaha MVP Health Care NALC Health Benefit Plan National Vision Administrators New Era Life Insurance Company Northwest Administrators Inc. NRECA Opticare of Utah Oxford Life Insurance Company Pan-American Life Insurance Co. PHCS Physicians Life Insurance Company Physicians Mutual Insurance Company PME - USA Healthcare Savings Principal Life Insurance Company Prominence HealthFirst Quick Trip Corporation Reliance Standard Life Insurance Company RH Administrators, Inc. SafeGuard Scott & White Health Plan Sentinel Plan Shenandoah Life Insurance Company Spectera / OptumHealth Starmark State Farm Health Insuance Superior Vision Tall Tree Administrators test carrier for ICD-10 Texas Municipal League Texas Mutual Insurance TML IEBP Transamerica Life Insurance Co Tricare South Region UMR - United Healthcare 30541 Unicare State Indemnity United Claim Solutions United Health Shared Services United HealthCare UnitedHealth Integrated Services UnitedHealthcare Oxford UnitedHealthCare StudentResources UPMC Health Plan Vision Benefits of America Vision Care Advantage - VCA Vision Service Plan Woodmen of the World/Assured Life Assoc. WPS Health Insurance Zurich American Ins. Comp.
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:

Primary Vision

Insurance Information

Insurance Name:	None AARP Accident Fund Administrative Concepts, Inc. Advantica Benefit Aetna Aetna-American Continental Ins. Co. Aflac All Savers Alliance Health and life ins. co. Allstate American Heritage Life Ins. Co Always Care Anchor Claims Management Assurant Health Avesis Insurance Inc. AXIS-CR England Insurance Best Life and Health Insurance Company Block Vision of Texas, Inc. Blue Cross Blue Shield Boone-Chapman Benefit Administrators, In Bunch and Associates Care N Care CDS Group Health CHAMPVA ChoiceCare Network Christian Brothers Employee Benefit Trus Cigna Cigna - APWU Cincinnati Insurance Company Coast to Coast Collections CoreSource COSE Medical Mutual Coventry Health Care, Inc. Crime Victim Services Davis Vision Deseret Mutual DO NOT USE XXX AARP Medicare UHC DO NOT USE XXX Anthem Blue Cross DO NOT USE XXX BCBS Medicare Advantage DO NOT USE XXX BCBS of Arkansas DO NOT USE XXX BCBS of Kansas City DO NOT USE XXX BCBS of Louisiana DO NOT USE XXX BCBS of Michigan DO NOT USE XXX BCBS of Mississippi DO NOT USE XXX BCBS of Nebraska DO NOT USE XXX BCBS of North Carolina DO NOT USE XXX CIGNA HealthCare DO NOT USE XXX CIGNA International DO NOT USE XXX UHC - Micare Complete DO NOT USE XXX UHC Mcare Solutions Envolve Vision of Texas/OptiCareManaged Eyemed Vision Care First Health Freedom Life Insurance Co.of America Gallagher Basset GEHA GPA Group Resources Guarantee Trust Life ins. GWH-Cigna Open Access Plus GWH-Cigna PPO Hanover Insurance HealthAmerica HealthComp HealthLink Open Access HealthSCOPE HealthSmart Preferred Care Hometown Health Humana Humana One Humana/Vision Comp Benefits IMG Kaiser Permanente Ins. Co. Keller Foundations 1130 Liberty Healthshare Liberty Mutual Lifestyle Health Plans Manhattan Life Insurance Company Medcost Preferred Medi-Share Medica Medicare Medicare Complete Medipac Assistance International Inc. Meritan Health MES Vision Met Life Claims MHBP Mutual of Omaha MVP Health Care NALC Health Benefit Plan National Vision Administrators New Era Life Insurance Company Northwest Administrators Inc. NRECA Opticare of Utah Oxford Life Insurance Company Pan-American Life Insurance Co. PHCS Physicians Life Insurance Company Physicians Mutual Insurance Company PME - USA Healthcare Savings Principal Life Insurance Company Prominence HealthFirst Quick Trip Corporation Reliance Standard Life Insurance Company RH Administrators, Inc. SafeGuard Scott & White Health Plan Sentinel Plan Shenandoah Life Insurance Company Spectera / OptumHealth Starmark State Farm Health Insuance Superior Vision Tall Tree Administrators test carrier for ICD-10 Texas Municipal League Texas Mutual Insurance TML IEBP Transamerica Life Insurance Co Tricare South Region UMR - United Healthcare 30541 Unicare State Indemnity United Claim Solutions United Health Shared Services United HealthCare UnitedHealth Integrated Services UnitedHealthcare Oxford UnitedHealthCare StudentResources UPMC Health Plan Vision Benefits of America Vision Care Advantage - VCA Vision Service Plan Woodmen of the World/Assured Life Assoc. WPS Health Insurance Zurich American Ins. Comp.
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 Accident Fund Administrative Concepts, Inc. Advantica Benefit Aetna Aetna-American Continental Ins. Co. Aflac All Savers Alliance Health and life ins. co. Allstate American Heritage Life Ins. Co Always Care Anchor Claims Management Assurant Health Avesis Insurance Inc. AXIS-CR England Insurance Best Life and Health Insurance Company Block Vision of Texas, Inc. Blue Cross Blue Shield Boone-Chapman Benefit Administrators, In Bunch and Associates Care N Care CDS Group Health CHAMPVA ChoiceCare Network Christian Brothers Employee Benefit Trus Cigna Cigna - APWU Cincinnati Insurance Company Coast to Coast Collections CoreSource COSE Medical Mutual Coventry Health Care, Inc. Crime Victim Services Davis Vision Deseret Mutual DO NOT USE XXX AARP Medicare UHC DO NOT USE XXX Anthem Blue Cross DO NOT USE XXX BCBS Medicare Advantage DO NOT USE XXX BCBS of Arkansas DO NOT USE XXX BCBS of Kansas City DO NOT USE XXX BCBS of Louisiana DO NOT USE XXX BCBS of Michigan DO NOT USE XXX BCBS of Mississippi DO NOT USE XXX BCBS of Nebraska DO NOT USE XXX BCBS of North Carolina DO NOT USE XXX CIGNA HealthCare DO NOT USE XXX CIGNA International DO NOT USE XXX UHC - Micare Complete DO NOT USE XXX UHC Mcare Solutions Envolve Vision of Texas/OptiCareManaged Eyemed Vision Care First Health Freedom Life Insurance Co.of America Gallagher Basset GEHA GPA Group Resources Guarantee Trust Life ins. GWH-Cigna Open Access Plus GWH-Cigna PPO Hanover Insurance HealthAmerica HealthComp HealthLink Open Access HealthSCOPE HealthSmart Preferred Care Hometown Health Humana Humana One Humana/Vision Comp Benefits IMG Kaiser Permanente Ins. Co. Keller Foundations 1130 Liberty Healthshare Liberty Mutual Lifestyle Health Plans Manhattan Life Insurance Company Medcost Preferred Medi-Share Medica Medicare Medicare Complete Medipac Assistance International Inc. Meritan Health MES Vision Met Life Claims MHBP Mutual of Omaha MVP Health Care NALC Health Benefit Plan National Vision Administrators New Era Life Insurance Company Northwest Administrators Inc. NRECA Opticare of Utah Oxford Life Insurance Company Pan-American Life Insurance Co. PHCS Physicians Life Insurance Company Physicians Mutual Insurance Company PME - USA Healthcare Savings Principal Life Insurance Company Prominence HealthFirst Quick Trip Corporation Reliance Standard Life Insurance Company RH Administrators, Inc. SafeGuard Scott & White Health Plan Sentinel Plan Shenandoah Life Insurance Company Spectera / OptumHealth Starmark State Farm Health Insuance Superior Vision Tall Tree Administrators test carrier for ICD-10 Texas Municipal League Texas Mutual Insurance TML IEBP Transamerica Life Insurance Co Tricare South Region UMR - United Healthcare 30541 Unicare State Indemnity United Claim Solutions United Health Shared Services United HealthCare UnitedHealth Integrated Services UnitedHealthcare Oxford UnitedHealthCare StudentResources UPMC Health Plan Vision Benefits of America Vision Care Advantage - VCA Vision Service Plan Woodmen of the World/Assured Life Assoc. WPS Health Insurance Zurich American Ins. Comp.
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 Vision

Insurance Information

Insurance Name:	None AARP Accident Fund Administrative Concepts, Inc. Advantica Benefit Aetna Aetna-American Continental Ins. Co. Aflac All Savers Alliance Health and life ins. co. Allstate American Heritage Life Ins. Co Always Care Anchor Claims Management Assurant Health Avesis Insurance Inc. AXIS-CR England Insurance Best Life and Health Insurance Company Block Vision of Texas, Inc. Blue Cross Blue Shield Boone-Chapman Benefit Administrators, In Bunch and Associates Care N Care CDS Group Health CHAMPVA ChoiceCare Network Christian Brothers Employee Benefit Trus Cigna Cigna - APWU Cincinnati Insurance Company Coast to Coast Collections CoreSource COSE Medical Mutual Coventry Health Care, Inc. Crime Victim Services Davis Vision Deseret Mutual DO NOT USE XXX AARP Medicare UHC DO NOT USE XXX Anthem Blue Cross DO NOT USE XXX BCBS Medicare Advantage DO NOT USE XXX BCBS of Arkansas DO NOT USE XXX BCBS of Kansas City DO NOT USE XXX BCBS of Louisiana DO NOT USE XXX BCBS of Michigan DO NOT USE XXX BCBS of Mississippi DO NOT USE XXX BCBS of Nebraska DO NOT USE XXX BCBS of North Carolina DO NOT USE XXX CIGNA HealthCare DO NOT USE XXX CIGNA International DO NOT USE XXX UHC - Micare Complete DO NOT USE XXX UHC Mcare Solutions Envolve Vision of Texas/OptiCareManaged Eyemed Vision Care First Health Freedom Life Insurance Co.of America Gallagher Basset GEHA GPA Group Resources Guarantee Trust Life ins. GWH-Cigna Open Access Plus GWH-Cigna PPO Hanover Insurance HealthAmerica HealthComp HealthLink Open Access HealthSCOPE HealthSmart Preferred Care Hometown Health Humana Humana One Humana/Vision Comp Benefits IMG Kaiser Permanente Ins. Co. Keller Foundations 1130 Liberty Healthshare Liberty Mutual Lifestyle Health Plans Manhattan Life Insurance Company Medcost Preferred Medi-Share Medica Medicare Medicare Complete Medipac Assistance International Inc. Meritan Health MES Vision Met Life Claims MHBP Mutual of Omaha MVP Health Care NALC Health Benefit Plan National Vision Administrators New Era Life Insurance Company Northwest Administrators Inc. NRECA Opticare of Utah Oxford Life Insurance Company Pan-American Life Insurance Co. PHCS Physicians Life Insurance Company Physicians Mutual Insurance Company PME - USA Healthcare Savings Principal Life Insurance Company Prominence HealthFirst Quick Trip Corporation Reliance Standard Life Insurance Company RH Administrators, Inc. SafeGuard Scott & White Health Plan Sentinel Plan Shenandoah Life Insurance Company Spectera / OptumHealth Starmark State Farm Health Insuance Superior Vision Tall Tree Administrators test carrier for ICD-10 Texas Municipal League Texas Mutual Insurance TML IEBP Transamerica Life Insurance Co Tricare South Region UMR - United Healthcare 30541 Unicare State Indemnity United Claim Solutions United Health Shared Services United HealthCare UnitedHealth Integrated Services UnitedHealthcare Oxford UnitedHealthCare StudentResources UPMC Health Plan Vision Benefits of America Vision Care Advantage - VCA Vision Service Plan Woodmen of the World/Assured Life Assoc. WPS Health Insurance Zurich American Ins. Comp.
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

Chief Complaint

Reason For Visit	New Patient Glasses Only New Patient Glasses and Contacts Established Patient Glasses Only Existing Patient Glasses and Contacts Other
Chief Complaint

Review Of Ocular Systems

Last Eye Exam
Eye Meds/Drops
Ocular History
Family Ocular History

Medical History

Primary Care Physician
Medical History
Family Medical History
Medications
Drug Allergies	No known drug allergies Amoxicillin Ceclor Hydrocodone Peanuts Penicillin Sulfa Tramadol Other
Pregnancy or Nursing	No Nursing Pregnant Other

Diabetes Report

Type	Type 1 Type 2 Gestational Prediabetes Other
Year of diagnosis	Other
HbA1C	Unknown Other
Last fasting blood sugar	Unknown Other
Patient reports under control	Yes No Other

Social History

Occupation		Hobbies
Smoking Status	Current every day smoker Current some day smoker (not daily) Former smoker (no longer smokes) Heavy smoker (>10 cigs/day) Light smoker (<10 cigs/day) Never smoker (<100 cigs equiv) Smoker (current status unknown) Unknown if ever smoked Other	Alcohol	No Yes Occasionally Socially Other	Recreational Drugs	No Yes Other

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