Welcome to Eyes of the World Online Patient Form

Demographics

Patient Information

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

Address:*
City:*		State:*	OR 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 MO MT NE NV PA RI SC SD TN UT VT WA ZipCode:*

Home Phone:*		Work Phone:
Other Phone:		Alerts:
Cell Phone:*		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN (last 4 digits)		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

Billing Information

Is The Billing Address Different?

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

Address

City	State	ZipCode
	OR 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 MO MT NE NV PA RI SC SD TN UT VT WA

Home Phone:
Work Phone:

Primary Vision

Insurance Information

Insurance Name:	None New Insurance AARP Abcam Advantica Aetna AlaskaCare/HealthSmart Allegiance Always Care Amerigroup Ameritas Assurant Avesis Provider Bakers Trust Bankers Life Insurance BCBS Blue Card Benefit Management Services Best Life Capital District Physicians HC Network Carefirst Carrington Champva Cigna Colorado Choice Health Plan Connecticare (Claims) Coventry Health Care Cow Creek Contract Health Service Credentialing CSI CTGR Health Plan Cypress Davis Discount Davis Vision Ely Shoshone Tribe Employee Benefit Management Services Envolve (other than TOHP) Envolve (Trillium Vision OHP) EPUD Eyemed FamilyCare CCO Farmers FEP BlueCross BlueShield First Choice Health Flores and Assoc. Foundation for Medical Care (COS) GEHA GPM Life Great West Care Green Valley Rehab Group Health Guardian Health Choice Health Comp Health Net Health Net of California Health Partners Health Republic Health Share of Oregon Health Smart Benefit Solutions HMA Hometown Health HumanaVision IAC Individual Assurance Co. INTERCOMMUNITY HEALTH NETWORK (Sweep) Kaiser Permanente Lifemap LifeWise Healthplan OR Lincoln Financial Group Mailhandlers Benefit Plan Medicaid Oregon Medicare Oregon Medico Medico Mega Health and Life Meritain Meritain (PeaceHealth Employees) MESO Moda Health Plan Mutual of Omaha Nationwide Specialty Health Claims NBN Nesika Health Group (Shasta) Nordian North American Division Benefit Health Care (Health Scope Benefits) NVA Oregon's Health Co-op Oregon Processors Employees Trust Pacific Source Pacific Source Comm. Solutions (OHP) Pacific Source Medicare Preferred Health Systems Principal Financial Group Progressive Providence Health Plan Providence Preferred Railroad Medicare Regence BCBS of Oregon Regence Group Admin Regence Innova Regence MedAdvantage Rehn & Associates Reliance Standard - Vision SAIF Samaritan Advantage Health Plan Samaritan Choice Plans Samaritan Health IHN Select Benefit Administrators of America (WI) Select Health Shasta Benefit Admin. Sierra HealthCare Options South Carolina Blues Spectera State Farm Sterling Stonebridge Summerlin Superior Vision The Standard TM Claims Service, INC Today's Options TPM TransAmerica Travelers TRICARE Oregon (WEST-WPS) UHC Trillium Commerical Products Trillium Medical OHP Trillium Medicare (Advantage) Triwest Trusteed Plans Service Corporation Tufts Health Plan Medicare Preferred UMR Union Pacific Railroad Employees Health System United Health Care United of Omaha Life Insurance Co. US Benefits (part of the Prov Pref group) VA VBA Vision Benefits of America VSP Washington Teamsters Welfare Trust Wellcare Wellcare Private Fee For Service Plans Wells Fargo Insurance Services Wells Fargo Third Party Administrators, Inc. Western Benefits, INC White Bird Clinic Willamette Valley Comm. Health Wisconsin Electrical Employees Benefit Funds Zenith Rocky Mountain UFCW
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 New Insurance AARP Abcam Advantica Aetna AlaskaCare/HealthSmart Allegiance Always Care Amerigroup Ameritas Assurant Avesis Provider Bakers Trust Bankers Life Insurance BCBS Blue Card Benefit Management Services Best Life Capital District Physicians HC Network Carefirst Carrington Champva Cigna Colorado Choice Health Plan Connecticare (Claims) Coventry Health Care Cow Creek Contract Health Service Credentialing CSI CTGR Health Plan Cypress Davis Discount Davis Vision Ely Shoshone Tribe Employee Benefit Management Services Envolve (other than TOHP) Envolve (Trillium Vision OHP) EPUD Eyemed FamilyCare CCO Farmers FEP BlueCross BlueShield First Choice Health Flores and Assoc. Foundation for Medical Care (COS) GEHA GPM Life Great West Care Green Valley Rehab Group Health Guardian Health Choice Health Comp Health Net Health Net of California Health Partners Health Republic Health Share of Oregon Health Smart Benefit Solutions HMA Hometown Health HumanaVision IAC Individual Assurance Co. INTERCOMMUNITY HEALTH NETWORK (Sweep) Kaiser Permanente Lifemap LifeWise Healthplan OR Lincoln Financial Group Mailhandlers Benefit Plan Medicaid Oregon Medicare Oregon Medico Medico Mega Health and Life Meritain Meritain (PeaceHealth Employees) MESO Moda Health Plan Mutual of Omaha Nationwide Specialty Health Claims NBN Nesika Health Group (Shasta) Nordian North American Division Benefit Health Care (Health Scope Benefits) NVA Oregon's Health Co-op Oregon Processors Employees Trust Pacific Source Pacific Source Comm. Solutions (OHP) Pacific Source Medicare Preferred Health Systems Principal Financial Group Progressive Providence Health Plan Providence Preferred Railroad Medicare Regence BCBS of Oregon Regence Group Admin Regence Innova Regence MedAdvantage Rehn & Associates Reliance Standard - Vision SAIF Samaritan Advantage Health Plan Samaritan Choice Plans Samaritan Health IHN Select Benefit Administrators of America (WI) Select Health Shasta Benefit Admin. Sierra HealthCare Options South Carolina Blues Spectera State Farm Sterling Stonebridge Summerlin Superior Vision The Standard TM Claims Service, INC Today's Options TPM TransAmerica Travelers TRICARE Oregon (WEST-WPS) UHC Trillium Commerical Products Trillium Medical OHP Trillium Medicare (Advantage) Triwest Trusteed Plans Service Corporation Tufts Health Plan Medicare Preferred UMR Union Pacific Railroad Employees Health System United Health Care United of Omaha Life Insurance Co. US Benefits (part of the Prov Pref group) VA VBA Vision Benefits of America VSP Washington Teamsters Welfare Trust Wellcare Wellcare Private Fee For Service Plans Wells Fargo Insurance Services Wells Fargo Third Party Administrators, Inc. Western Benefits, INC White Bird Clinic Willamette Valley Comm. Health Wisconsin Electrical Employees Benefit Funds Zenith Rocky Mountain UFCW
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 Medical

Insurance Information

Insurance Name:	None AARP Abcam Advantica Aetna AlaskaCare/HealthSmart Allegiance Always Care Amerigroup Ameritas Assurant Avesis Provider Pin #64595 Bankers Life Insurance BCBS Blue Card Benefit Management Services Best Life Capital District Physicians HC Network Carefirst Carrington (see notes below) Champva Cigna Colorado Choice Health Plan Connecticare (Claims) Coventry Health Care Cow Creek Contract Health Service Credentialing CSI (Medicare Supplement) CTGR Health Plan Cypress Davis Discount Davis Vision Ely Shoshone Tribe Employee Benefit Management Services Envolve (other than TOHP) Envolve (Trillium Vision OHP) EPUD Eyemed FamilyCare CCO Farmers FEP BlueCross BlueShield First Choice Health Flores and Assoc. Foundation for Medical Care (COS) GEHA GPM Life Great West Care Green Valley Rehab Group Health Guardian Health Choice Health Comp Health Net Health Net of California Health Partners Health Republic Health Share of Oregon Health Smart Benefit Solutions HMA (for PH plans Call cordinated healthcare 1866.687.1110) Hometown Health HumanaVision IAC Individual Assurance Co. INTERCOMMUNITY HEALTH NETWORK (Sweep) Kaiser Permanente Lifemap LifeWise Healthplan OR Lincoln Financial Group Mailhandlers Benefit Plan Medicaid Oregon Medicare Oregon Medico Medico (Medicare supplement plans) Mega Health and Life payor id 59221 Meritain (Minneapolis address) MESO Moda Health Plan Mutual of Omaha Nationwide Specialty Health Claims NBN Nesika Health Group (Shasta) Nordian North American Division Benefit Health Care NVA get auth online see address below (not NW Vision Associates) Oregon's Health Co-op Oregon Processors Employees Trust Pacific Source Pacific Source Comm. Solutions (OHP) Pacific Source Medicare Preferred Health Systems Principal Financial Group Providence Health Plan Providence Preferred Railroad Medicare Regence BCBS of Oregon Regence Group Admin Regence Innova Regence MedAdvantage Rehn & Associates Reliance Standard - Vision SAIF Samaritan Advantage Health Plan Samaritan Choice Plans Samaritan Health IHN Select Benefit Administrators of America (WI) Select Health SHASTA ADMINSTRATIVE SVC Shasta Benefit Admin. Sierra HealthCare Options South Carolina Blues Spectera State Farm Sterling Stonebridge Summerlin Superior Vision The Standard TM Claims Service, INC Today's Options TPM TransAmerica Travelers TRICARE Oregon (WEST-WPS) UHC Trillium Commerical Products Trillium Medical OHP Trillium Medicare (Advantage) Triwest Trusteed Plans Service Corporation Tufts Health Plan Medicare Preferred UMR Union Pacific Railroad Employees Health System United Health Care United of Omaha Life Insurance Co. US Benefits (part of the Prov Pref group) VA VBA Vision Benefits of America VSP Washington Teamsters Welfare Trust Wellcare Wellcare Private Fee For Service Plans Wells Fargo Insurance Services Wells Fargo Third Party Administrators, Inc. (Form Western Benefits, INC White Bird Clinic Willamette Valley Comm. Health Wisconsin Electrical Employees Benefit Funds Zenith Rocky Mountain UFCW
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 Abcam Advantica Aetna AlaskaCare/HealthSmart Allegiance Always Care Amerigroup Ameritas Assurant Avesis Provider Pin #64595 Bankers Life Insurance BCBS Blue Card Benefit Management Services Best Life Capital District Physicians HC Network Carefirst Carrington (see notes below) Champva Cigna Colorado Choice Health Plan Connecticare (Claims) Coventry Health Care Cow Creek Contract Health Service Credentialing CSI (Medicare Supplement) CTGR Health Plan Cypress Davis Discount Davis Vision Ely Shoshone Tribe Employee Benefit Management Services Envolve (other than TOHP) Envolve (Trillium Vision OHP) EPUD Eyemed FamilyCare CCO Farmers FEP BlueCross BlueShield First Choice Health Flores and Assoc. Foundation for Medical Care (COS) GEHA GPM Life Great West Care Green Valley Rehab Group Health Guardian Health Choice Health Comp Health Net Health Net of California Health Partners Health Republic Health Share of Oregon Health Smart Benefit Solutions HMA (for PH plans Call cordinated healthcare 1866.687.1110) Hometown Health HumanaVision IAC Individual Assurance Co. INTERCOMMUNITY HEALTH NETWORK (Sweep) Kaiser Permanente Lifemap LifeWise Healthplan OR Lincoln Financial Group Mailhandlers Benefit Plan Medicaid Oregon Medicare Oregon Medico Medico (Medicare supplement plans) Mega Health and Life payor id 59221 Meritain (Minneapolis address) MESO Moda Health Plan Mutual of Omaha Nationwide Specialty Health Claims NBN Nesika Health Group (Shasta) Nordian North American Division Benefit Health Care NVA get auth online see address below (not NW Vision Associates) Oregon's Health Co-op Oregon Processors Employees Trust Pacific Source Pacific Source Comm. Solutions (OHP) Pacific Source Medicare Preferred Health Systems Principal Financial Group Providence Health Plan Providence Preferred Railroad Medicare Regence BCBS of Oregon Regence Group Admin Regence Innova Regence MedAdvantage Rehn & Associates Reliance Standard - Vision SAIF Samaritan Advantage Health Plan Samaritan Choice Plans Samaritan Health IHN Select Benefit Administrators of America (WI) Select Health SHASTA ADMINSTRATIVE SVC Shasta Benefit Admin. Sierra HealthCare Options South Carolina Blues Spectera State Farm Sterling Stonebridge Summerlin Superior Vision The Standard TM Claims Service, INC Today's Options TPM TransAmerica Travelers TRICARE Oregon (WEST-WPS) UHC Trillium Commerical Products Trillium Medical OHP Trillium Medicare (Advantage) Triwest Trusteed Plans Service Corporation Tufts Health Plan Medicare Preferred UMR Union Pacific Railroad Employees Health System United Health Care United of Omaha Life Insurance Co. US Benefits (part of the Prov Pref group) VA VBA Vision Benefits of America VSP Washington Teamsters Welfare Trust Wellcare Wellcare Private Fee For Service Plans Wells Fargo Insurance Services Wells Fargo Third Party Administrators, Inc. (Form Western Benefits, INC White Bird Clinic Willamette Valley Comm. Health Wisconsin Electrical Employees Benefit Funds Zenith Rocky Mountain UFCW
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

Medical History

Personal & Social History

Referred By:

Friend/Family Insurance Mailer Recall Walk-by/Drive-by Website/Internet Yellow Pages Other

Has a family member been seen by us? If yes, please give name:

Primary Care Physician:

Hobbies:

. Arts and Crafts Baseball Basketball Boating Bowling Cooking Cycling Dancing Excercising Fishing Football Golf Gardening Horses Hunting Jogging Lawn Work None Outdoors Painting Photography Piano Pogs Reading Running Sailing Scuba Sewing Skiing Soccer Softball Swimming Tennis T.V. Video Games Wake Boarding Weights Woodworking Other

Employer

University of Oregon 4J School District Market of Choice Self Employed Retired Other

Medical & Eye History

What is the main reason for scheduling an appointment today?

Routine Specific Issue Other

If there is a specific issue, please elaborate:

Last Eye Exam:

1 year ago 2 years ago 3 or more years ago less than 1 year ago never unknown Other

Do you wear glasses?

No Yes, full-time Yes, reading only Yes, distance only Other

Do you wear contact lenses?

No, not interested Yes, full-time wearer Yes, occasional only Worn in past, interested again No, may be interested Other

Type of contacts?

Soft, 1 month disposable Soft, 2 week disposable Soft, for astigmatism Soft, bifocal Soft, monovision Rigid Gas Perm Other

Do you or members of your immediate family have any of the following conditions? Adopted/Unknown Family History

	Self - All No	Family - All No	Relationship
Diabetes:*	yes no	yes no N/A	Father Mother Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other
High BP:*	no yes	no yes N/A	Father Mother Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other
Heart Condition:*	no yes	no yes N/A	Father Mother Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other
Thyroid Condition:*	no yes	no yes N/A	Father Mother Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other
Asthma:*	no yes	no yes N/A	Father Mother Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other
Sinus Issues:*	no yes	no yes N/A	Father Mother Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other
Cancer:*	no yes	no yes N/A	Father Mother Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other
Glaucoma:*	no yes	no yes N/A	Father Mother Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other
Lazy Eye:*	no yes	no yes N/A	Father Mother Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other
Macular Degen:*	no yes	no yes N/A	Father Mother Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other
Cataracts:*	no yes	no yes N/A	Father Mother Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other
Other:*	no yes	no yes N/A	Father Mother Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other

All No
Do you experience flashes of light?*	no yes Other
Do you experience floaters in your vision?*	no yes Other
Have you ever had an eye injury?*	no yes Other
Have you ever had eye surgery?*	no yes Other
Do you frequently have double vision?*	no yes Other
Are you troubled by frequent headaches?*	no yes Other
Are you pregnant/nursing?:*	No Yes Unsure

Are you taking any medications? If no, type 'None':*

Are you allergic to any medications? If no, type 'None':*

Other Health Conditions? If no, type 'None':*

Review of Systems

Please choose from the menu options or select "OTHER" to type your answer. Thank you!

All None

General:*	None Fever Chills Fatigue Unexplained Weight Loss/Gain Other	Skin:*	None Rash Growths Rosacea MRSA Infection Other
Ears, Nose, Throat:*	None Allergies/Sinus Problems Nose Bleeds Dry Mouth/Throat Ear Ache Hearing Problems Other	Neurological:*	None Headaches Numbness/Tingling Seizures Poor Balance Speech Problems Other
Cardiovascular:*	None Chest Pain Racing Heartbeat Palpitations Heart Condition Other	Psychiatric:*	None Depression Anxiety Insomnia Other
Respiratory:*	None Asthma Chronic Cough Shortness of Breath Wheezing Other	Endocrine:*	None Heat/Cold Intolerance Excessive Thirst Gland Condition Other
Genitourinary:	None Frequent Urination Painful Urination Yellow Jaundice Incontinence Other	Blood/Lymph:*	None Anemia Excessive/Prolonged Bleeding Unexplained Bruising Other
Gastrointestinal:*	None Constipation Diarrhea Acid Reflux Nausea Vomiting Other	Allergy/Immune:*	None Hives Lupus HIV AIDS Recurrent Infections Other
Musculoskeletal:*	None Arthritis Stiffness Swelling Muscle/Joint Pain Other

Dilation/Optomap Consent

As part of a comprehensive eye examination, it is recommended that ALL patients have the internal health of their eyes thoroughly evaluated every year, this is done by either having an Optomap retinal scan OR dilation. Common conditions, such as glaucoma, diabetes, macular degeneration, and even cancer can be discovered when the doctor evaluates the internal health of the eye. Selecting to have either the Optomap retinal image OR eye dilation will allow the doctor an extensive view of the retina during the examination.

*The Optomap Retinal Image captures a digital scan of the retina and does NOT require dilation. The scans become permanent records that will allow the doctor to compare any retinal changes annually.

*Dilation is the use of drops to temporarily dilate or enlarge the pupil. Your vision can be affected up to 4 hours.

THERE IS AN ADDITIONAL FEE OF $20.00 FOR THE OPTOMAP RETINAL EXAM WHICH IS NOT COVERED BY INSURANCE.

Please only check one.

I have read and understand the above, and agree to the Optomap Retinal Exam.
I have read and understand the above, and decline the Optomap Retinal Exam but I wish to have my eyes dilated.
I have read and understand the above, and decline both the Optomap Retinal Exam and dilation at this time.

Patient/Parent Signature:* Date:*
    Please type full legal name as electronic signature.

HIPAA, FINANCIAL & ELECTRONIC COMMUNICATION AGREEMENT

I hereby authorize Eyes of the World, Dr. Jerry Phillips, O.D., to furnish my insurance company(s) all medical information necessary to process any appropriate claim(s). I also authorize payment of benefits to Eyes of the World, Dr. Jerry Phillips, O.D. I accept full responsibility for ALL my incurred charges including charges which my insurance company may or may not cover. I am responsible for all charges incurred for the treatment/services I receive whether I have or may not have insurance. There will be a $30 NSF fee for returned checks.

I understand that Eyes of the World, Dr. Jerry Phillips, O.D., is committed to keeping my health information private. By signing below, I acknowledge that I have been presented a copy of the Notice of Privacy Practices.

My signature will serve as a protected health information document release, by signing below I am consenting for medical records be sent via digital communication (email/text) to myself, authorized party or to another facility. A copy of this signed, dated document dated document shall be as effective as the original.

  Patient/Parent Signature:* Date:*
    Please type full legal name as electronic signature.

CONTACT LENS PRESCRIPTION ACKNOWLEDGMENT

Contact Lens Prescription Signed Acknowledgment Form Included below is important information to review prior to receiving your contact lens prescription.

The Centers for Disease Control and Prevention (CDC) makes clear, "Contact lenses can provide many benefits, but they are not risk-free-especially if contact lens wearers don't practice healthy habits and take care of their contact lenses and supplies. If patients seek care quickly, most complications can be easily treated by an eye doctor. However, more serious infections can cause pain and even permanent vision loss, depending on the cause and how long the patient waits to seek treatment." Symptoms of Eye Infection include:

Irritated, red eyes

Worsening pain in or around the eyes-even after contact lens removal

Light sensitivity

Sudden blurry vision

Unusually watery eyes or discharge

The CDC recommends the following for contact lens wearers:
- Schedule a visit with your eye doctor at least once a year. - Take out your contacts and call your eye doctor if you have eye pain, discomfort, redness, or blurry vision. - Understand that eye infections that go untreated can lead to eye damage or even blindness.

The Food and Drug Administration (FDA) indicates:
- "To be sure that your eyes remain healthy you should not order lenses with a prescription that has expired or stock up on lenses right before the prescription is about to expire. It's safer to be re-checked by your eye care professional."

Sign below to acknowledge that you will be provided with a copy of your contact lens prescription at the completion of your contact lens fitting.

Electronic Patient / Parent Signature: Date:

Submit Data