Online Patient Forms Data Is Not Submitted Until You Go To Submit Data Tab! Demographics Next Page TitleFirstLastMISuffixNickname Mr. Mrs. Ms. Master Miss Dr. Rev. Fr. Address: Apt/Suite #: City: State: 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 ZipCode: Email: Cell Phone: Work Phone: Preferred Contact Method: Cell Phone Email SSN: Sex: Male Female Birthday: Occupation: Billing Information Is The Billing Address the Same? TitleFirstLastMISuffix Mr. Mrs. Ms. Master Miss Dr. Rev. Fr. AddressApt/Suite # CityStateZipCode 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: Next Page Previous PageNext Page Has Your Insurance Information Changed? Yes No If yes, please edit your history below Vision Insurance Insurance Information Insurance Name: None No Name AARP GROUP HEALTH INSURANCE ABB Contacts AETNA - Aetna AFLAC AID'S SERVICES OF AUSTIN Aliera Healthcare Allegiance Benefit Plan Management Inc. Allied Benefit System AlwaysCare Benefits, Inc. American Postal Workers Union (APWU) Health Plan Ameritas Amerivantage - WellMed Assurant Health AVESIS INC BANKERS LIFE AND CASUALTY BARTER ACCOUNTS-NEEDS AUTH BY OWNER BEECHSTREET (M S ADMIN. SER.) Benefit Alliance BLUE CROSS BLUE SHIELD - Blue Cross Blue Shield Boon-Chapman Benefit Administrators, Inc. Care Improvement Plus Caremark CENTRAL STATES HEALTH Central United Life ChampVA Charity Choctaw Nation Health Services Authority CIGNA - Cigna CMS Employee Benefit Plan Community First! Village Companion LIfe Continental Life Ins. Covenant Management Systems Coventry Health Care(NOT IN NETWORK) DAVIS VISION (We are NOT in Network!!) Dell Laser Consultants Disability Determination Svcs EBMS Employer Plan Services Entrust (TPA) Envolve Vision (formerly: OptiCare) Eye Lasik Austin EYEMED Eyetopia / Vision Care Direct Family Life Insurance FIRST HEALTH (Not in-network) FORTIS BENEFITS INSURANCE CO Freedom Life Insurance Company of America GEHA Golden Rule GREAT-WEST HEALTHCARE Group and Pension Administrators HARRINGTON BENEFIT SERVICES Health First HealthComp HealthPartners HEALTHSMART & BEECH STREET Heartland National Hill Country Eye Center Humana HUMANA CHOICECARE Humana EPO (WE ARE NOT PROVIDERS) HUMANA HMO (must get referral) Humana Medicare Humana One Kaiser Permanente Insurance Company KIDS HELPING KIDS Legal Request LensFerry (CooperVision) Liberty Health Share Lions Club Logistics Health, Inc. Loyal American Life Ins Co. M.E.S. Vision Makina Benefits Manhattan Life Insurance MEDICAID (NHIC) MEDICARE OF TEXAS - Medicare of Texas Medicare Supplement Plan Medico Insurance Company MediShare MEGA LIFE & HEALTH INSURANCE Meritain Health MetLife Monthly Payments Monumental Life Insurane Company MultiPlan (formerly PHCS) Mutual of Omaha Companies Nat'l Assoc of Letter Carriers Health Benefit Plan National Auto Sprinkler Industry National Benefit Administrators, Inc. National Vision Administrators New Era Life Insurance Company New Lens Vision Old Insurances (A through K) Old Insurances (R through Z) Old Surety Life Insurance Company Opticare of Utah Oscar (ACA pln - We are NOT providers) Palmetto Government Benefits A Perks Connect Program PHYSICIAN'S MUTUAL Physicians Health Choice PRINCIPAL LIFE INSURANCE CO. - Principal Life Insurance Co. Provident American Life and Health Insurance RailRoad Medicare Part B RAILROAD MEDICARE\METRAHEALTH Refractive Surgery & Diagnostic Center Reserve National Royal Neighbors of America (RNA) SCOTT AND WHITE HEALTH PLANS (Tier 1) Self Pay SETON HEALTH PLAN (IF card also says CIGNA, we are tier 2) Sierra Health & Life Insurance Company, INC Sightbox Simple Spectera Eyecare Networks / OptumHealth - Spectera STANDARD LIFE & ACCIDENT STARMARK STATE FARM INSURANCE Sterling Investors Insurance Co. Sterling Life Insurance Company SUPERIOR VISION SERVICES Texas Optometric Association Texas True Choice The Legal Connection TML INTERGOVERNMENTAL EMPLOYEE BENEFIT POOL - TML Insurance Co. TransAmerica Life Insurance Company TRAVELERS Tricare East Region Claims TriWest Healthcare Alliance UMR UNICARE UNITED AMERICAN INS CO United Healthcare United Healthcare HealthSelect USAA Vision Care Advantage Vision Care Plan/Humana Vision Vision One Discount Program Vision Service Plan (VSP) Vision USA WEBTPA WORKMAN'S COMPENSATION 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: Previous PageNext Page Medical Insurance Previous PageNext Page Has Your Insurance Information Changed? Yes No If yes, please edit your history below Insurance Information Insurance Name: None No Name AARP GROUP HEALTH INSURANCE ABB Contacts AETNA - Aetna AFLAC AID'S SERVICES OF AUSTIN Aliera Healthcare Allegiance Benefit Plan Management Inc. Allied Benefit System AlwaysCare Benefits, Inc. American Postal Workers Union (APWU) Health Plan Ameritas Amerivantage - WellMed Assurant Health AVESIS INC BANKERS LIFE AND CASUALTY BARTER ACCOUNTS-NEEDS AUTH BY OWNER BEECHSTREET (M S ADMIN. SER.) Benefit Alliance BLUE CROSS BLUE SHIELD - Blue Cross Blue Shield Boon-Chapman Benefit Administrators, Inc. Care Improvement Plus Caremark CENTRAL STATES HEALTH Central United Life ChampVA Charity Choctaw Nation Health Services Authority CIGNA - Cigna CMS Employee Benefit Plan Community First! Village Companion LIfe Continental Life Ins. Covenant Management Systems Coventry Health Care(NOT IN NETWORK) DAVIS VISION (We are NOT in Network!!) Dell Laser Consultants Disability Determination Svcs EBMS Employer Plan Services Entrust (TPA) Envolve Vision (formerly: OptiCare) Eye Lasik Austin EYEMED Eyetopia / Vision Care Direct Family Life Insurance FIRST HEALTH (Not in-network) FORTIS BENEFITS INSURANCE CO Freedom Life Insurance Company of America GEHA Golden Rule GREAT-WEST HEALTHCARE Group and Pension Administrators HARRINGTON BENEFIT SERVICES Health First HealthComp HealthPartners HEALTHSMART & BEECH STREET Heartland National Hill Country Eye Center Humana HUMANA CHOICECARE Humana EPO (WE ARE NOT PROVIDERS) HUMANA HMO (must get referral) Humana Medicare Humana One Kaiser Permanente Insurance Company KIDS HELPING KIDS Legal Request LensFerry (CooperVision) Liberty Health Share Lions Club Logistics Health, Inc. Loyal American Life Ins Co. M.E.S. Vision Makina Benefits Manhattan Life Insurance MEDICAID (NHIC) MEDICARE OF TEXAS - Medicare of Texas Medicare Supplement Plan Medico Insurance Company MediShare MEGA LIFE & HEALTH INSURANCE Meritain Health MetLife Monthly Payments Monumental Life Insurane Company MultiPlan (formerly PHCS) Mutual of Omaha Companies Nat'l Assoc of Letter Carriers Health Benefit Plan National Auto Sprinkler Industry National Benefit Administrators, Inc. National Vision Administrators New Era Life Insurance Company New Lens Vision Old Insurances (A through K) Old Insurances (R through Z) Old Surety Life Insurance Company Opticare of Utah Oscar (ACA pln - We are NOT providers) Palmetto Government Benefits A Perks Connect Program PHYSICIAN'S MUTUAL Physicians Health Choice PRINCIPAL LIFE INSURANCE CO. - Principal Life Insurance Co. Provident American Life and Health Insurance RailRoad Medicare Part B RAILROAD MEDICARE\METRAHEALTH Refractive Surgery & Diagnostic Center Reserve National Royal Neighbors of America (RNA) SCOTT AND WHITE HEALTH PLANS (Tier 1) Self Pay SETON HEALTH PLAN (IF card also says CIGNA, we are tier 2) Sierra Health & Life Insurance Company, INC Sightbox Simple Spectera Eyecare Networks / OptumHealth - Spectera STANDARD LIFE & ACCIDENT STARMARK STATE FARM INSURANCE Sterling Investors Insurance Co. Sterling Life Insurance Company SUPERIOR VISION SERVICES Texas Optometric Association Texas True Choice The Legal Connection TML INTERGOVERNMENTAL EMPLOYEE BENEFIT POOL - TML Insurance Co. TransAmerica Life Insurance Company TRAVELERS Tricare East Region Claims TriWest Healthcare Alliance UMR UNICARE UNITED AMERICAN INS CO United Healthcare United Healthcare HealthSelect USAA Vision Care Advantage Vision Care Plan/Humana Vision Vision One Discount Program Vision Service Plan (VSP) Vision USA WEBTPA WORKMAN'S COMPENSATION 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: Previous PageNext Page Medical History Previous PageNext Page Has Your Medical History Changed? Yes No If yes, please edit your history below Primary Reason For Visit Today Looking For Frames Or Purchasing Glasses Today? Yes No Last Eye Doctor: Primary Care Physician: Akin, Mark Caven David Martin Doesn't Have One Doesn't Remember E.R. David Enriquez Fred Martin Glaze Gray, Lynne Jeffrey Hallett Jess Thompson King Kangos Martinez Merryman None Ream Silverthorne Stavinoha Terry Sherman Winn Warren, Pamela Other Preferred Pharmacy Medications (including OTC): - No current medications Allergies: - No Known Drug Allergies Environmental Drugs Latex Molds None Perfumes Seasonal Other Preferred Language (Declined) English Spanish Smoking Status Current Every Day Smoker Current Some Day Smoker Former Smoker Never Smoker Smoker, Current Status Unknown Unknown if Ever Smoked Do Your Eyes Sting, Burn, Itch, Or Feel Dry? Have You Had An Eye Injury Or Been Diagnosed With Cataracts, Lazy Eye, Retinal Problems, Or Glaucoma? Do You Have a History Of Headaches? Arthritis? Asthma? Diabetes? High Blood Pressure? Heart Problems? Inflammatory Bowel Disease? Seizures? Thyroid Problems? Do You Smoke? Are You Pregnant? Are You Nursing? Are You HIV+? If Yes, Please List Below. Does Anyone In Your Family Have/Had Diabetes? Lupus? Cancer? High Blood Pressure? Heart Problems? Auto-Immune Disease? If Yes, Please List Below. Does Anyone In Your Family Have/Had Glaucoma? Macular Degeneration? Retinal Detachment? Other Retinal Disorders? If Yes, Please List Below. Any Other Relevant Information? Previous PageNext Page Reading Symptoms Previous PageNext Page I wear glasses Full time Part time Sometimes Far only Near only Both If yes, age when first worn: 6 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years Other I wear contact lenses Full time Part time Sometimes If yes, age when first worn: 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years Other I work on a computer Glasses worn: Yes No If yes, hours per day: 1 2 3 4 5 6 7 8 9 10 Other Previous PageNext Page Previous PageNext Page COVID-19 SCREENING Within The Last 14 Days Have You Experienced Any Of The Following Symptoms: Condition Yes No Fever Cough Shortness Of Breath Or Difficulty Breathing Chills Repeated Shaking With Chills Muscle Pain Sore Throat New Loss Of Taste Or Smell Have You Traveled In The Last 14 Days? Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days? Have You Or A Member Of Your Household Had Close Contact With Or Cared For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days? Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis, Or Have You Been Asked To Quarantine? Previous PageNext Page Previous Page Submit Data / Patient Signatures We Will Not Receive Your Information Until You Press The Submit Button Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below. Notice of Privacy Practices View Notice of Privacy Practices Form Patient Signature: Date: Previous Page Data Is Not Submitted Until You Go To Submit Data Tab!