Online Patient Form
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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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