New Patient Form
Demographics
Title
First
Last
MI
Suffix
Nickname
Dr.
Mr.
Mrs.
Miss
Ms.
Address:
City:
State/ZipCode
WA
ID
MT
Home Phone:
Work Phone:
Other Phone:
Alerts:
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
SINGLE
MARRIED
WIDOWED
Employer/School Name
Misc/Guardian
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other Race
Patient Declined to Specify
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
Preferred Language
English
Spanish
French
option value="Patient Declined to Specify">Patient Declined to Specify
Smoking Status
Never smoker (<100 lifetime cigarettes or equivalent quantity of cigar or pipe smoke)
Former smoker (no longer smokes)
Current some day smoker (not daily)
Light smoker (<10 cigs/day)
Heavy smoker (>10 cigs/day)
Smoker (current status unknown)
Unknown if ever smoked
Other
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Dr.
Mr.
Mrs.
Miss
Ms.
Address
City
State
ZipCode
WA
ID
MT
Home Phone:
Work Phone:
Primary
Insurance Information
Insurance Name:
None
AARP Healthcare Options
AARP Medicare Complete
Administrators West
Advantra Freedom
Adventist Risk Management
Aetna
Aetna Medicare
Allegiance Benefit Plan (FCHN)
Ameriben/ IEC Group (FCHN)
Ameritas
Asuris Northwest Health
Asuris NW Health MedAdvantage
Avesis Inc.
Bankers Life and Casualty Company
BC/BS Federal Employee Program
Carpenters Health & Security Plan (FCHN)
Champ VA
Cigna Healthcare
Cigna International
Coastal Administrative Services (FCHN)
Community Health Plan Medicare Advantage Plan
Community Health Plan of WA
Community Health Plan of WA (PEBB Claims)
Cooperative Benefit Administration
Coresource
DSHS
EBMS
EBMS (FCHN)
Empire Health Services (FCHN)
Eucon Health Plan C/O Ameriben (FCHN)
EyeMed
First Choice Administrators (FCHN)
First Choice Health Network (FCHN)
Fiserv Health
GEHA (FCHN)
Great West Healthcare
Group Health Options (FCHN)
HCS
Health Comp (FCHN)
Health Net
HMA
Humana
Humana Gold Choice
Humana VCP Specialty Benefits
IEEWT (FCHN)
INHS
Inland Empire Teamsters Trust (FCHN)
Insurance Management Administration
KPS Health Plans (FCHN)
LEOFF Health & Welfare (FCHN)
Lifewise Healthplan of WA
Loomis Benefits West (FCHN)
Maksin Management Corporation
Medicare Part B
Medicare Railroad
Mercer Administration
Meritain Health (FCHN)
MESO
Mid-West National
Monaco Enterprise (FCHN)
Mutual of Omaha
Northwest Benefit Network
Northwest Plumbers & Pipefitters (FCHN)
Northwest Sheetmetal Workers (FCHN)
Pacific Underwriters (FCHN)
PHCO
Phillips Administrative Service, Inc
Premera Blue Cross
Principal Financial Group (FCHN)
Providence Health Plan (FCHN)
Providence Health Plan (FCHN)
RBMS
Regence Blue Shield of Idaho
Regence MedAdvantage
Secure Horizon Direct
Secure Horizons
Sound Health (FCHN)
State Farm Insurance
Sterling Basic Plus
Sterling Medicare Select
Sterling Option 1/ Option 2
Superior Vision
TPM Trust
TPSC
Tricare
Tricare For Life
Trusteed Plans (FCHN)
UFCW Welfare Trust (FCHN)
Uniform Medical Plan
United Healthcare
VSP
WA/ID Carpenters-Employers Health
Washington Employers Trust (FCHN)
Wausau Benefits
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:
Employer/School:
Secondary
Insurance Information
Insurance Name:
None
AARP Healthcare Options
AARP Medicare Complete
Administrators West
Advantra Freedom
Adventist Risk Management
Aetna
Aetna Medicare
Allegiance Benefit Plan (FCHN)
Ameriben/ IEC Group (FCHN)
Ameritas
Asuris Northwest Health
Asuris NW Health MedAdvantage
Avesis Inc.
Bankers Life and Casualty Company
BC/BS Federal Employee Program
Carpenters Health & Security Plan (FCHN)
Champ VA
Cigna Healthcare
Cigna International
Coastal Administrative Services (FCHN)
Community Health Plan Medicare Advantage Plan
Community Health Plan of WA
Community Health Plan of WA (PEBB Claims)
Cooperative Benefit Administration
Coresource
DSHS
EBMS
EBMS (FCHN)
Empire Health Services (FCHN)
Eucon Health Plan C/O Ameriben (FCHN)
EyeMed
First Choice Administrators (FCHN)
First Choice Health Network (FCHN)
Fiserv Health
GEHA (FCHN)
Great West Healthcare
Group Health Options (FCHN)
HCS
Health Comp (FCHN)
Health Net
HMA
Humana
Humana Gold Choice
Humana VCP Specialty Benefits
IEEWT (FCHN)
INHS
Inland Empire Teamsters Trust (FCHN)
Insurance Management Administration
KPS Health Plans (FCHN)
LEOFF Health & Welfare (FCHN)
Lifewise Healthplan of WA
Loomis Benefits West (FCHN)
Maksin Management Corporation
Medicare Part B
Medicare Railroad
Mercer Administration
Meritain Health (FCHN)
MESO
Mid-West National
Monaco Enterprise (FCHN)
Mutual of Omaha
Northwest Benefit Network
Northwest Plumbers & Pipefitters (FCHN)
Northwest Sheetmetal Workers (FCHN)
Pacific Underwriters (FCHN)
PHCO
Phillips Administrative Service, Inc
Premera Blue Cross
Principal Financial Group (FCHN)
Providence Health Plan (FCHN)
Providence Health Plan (FCHN)
RBMS
Regence Blue Shield of Idaho
Regence MedAdvantage
Secure Horizon Direct
Secure Horizons
Sound Health (FCHN)
State Farm Insurance
Sterling Basic Plus
Sterling Medicare Select
Sterling Option 1/ Option 2
Superior Vision
TPM Trust
TPSC
Tricare
Tricare For Life
Trusteed Plans (FCHN)
UFCW Welfare Trust (FCHN)
Uniform Medical Plan
United Healthcare
VSP
WA/ID Carpenters-Employers Health
Washington Employers Trust (FCHN)
Wausau Benefits
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:
Employer/School:
Tertiary
Insurance Information
Insurance Name:
None
AARP Healthcare Options
AARP Medicare Complete
Administrators West
Advantra Freedom
Adventist Risk Management
Aetna
Aetna Medicare
Allegiance Benefit Plan (FCHN)
Ameriben/ IEC Group (FCHN)
Ameritas
Asuris Northwest Health
Asuris NW Health MedAdvantage
Avesis Inc.
Bankers Life and Casualty Company
BC/BS Federal Employee Program
Carpenters Health & Security Plan (FCHN)
Champ VA
Cigna Healthcare
Cigna International
Coastal Administrative Services (FCHN)
Community Health Plan Medicare Advantage Plan
Community Health Plan of WA
Community Health Plan of WA (PEBB Claims)
Cooperative Benefit Administration
Coresource
DSHS
EBMS
EBMS (FCHN)
Empire Health Services (FCHN)
Eucon Health Plan C/O Ameriben (FCHN)
EyeMed
First Choice Administrators (FCHN)
First Choice Health Network (FCHN)
Fiserv Health
GEHA (FCHN)
Great West Healthcare
Group Health Options (FCHN)
HCS
Health Comp (FCHN)
Health Net
HMA
Humana
Humana Gold Choice
Humana VCP Specialty Benefits
IEEWT (FCHN)
INHS
Inland Empire Teamsters Trust (FCHN)
Insurance Management Administration
KPS Health Plans (FCHN)
LEOFF Health & Welfare (FCHN)
Lifewise Healthplan of WA
Loomis Benefits West (FCHN)
Maksin Management Corporation
Medicare Part B
Medicare Railroad
Mercer Administration
Meritain Health (FCHN)
MESO
Mid-West National
Monaco Enterprise (FCHN)
Mutual of Omaha
Northwest Benefit Network
Northwest Plumbers & Pipefitters (FCHN)
Northwest Sheetmetal Workers (FCHN)
Pacific Underwriters (FCHN)
PHCO
Phillips Administrative Service, Inc
Premera Blue Cross
Principal Financial Group (FCHN)
Providence Health Plan (FCHN)
Providence Health Plan (FCHN)
RBMS
Regence Blue Shield of Idaho
Regence MedAdvantage
Secure Horizon Direct
Secure Horizons
Sound Health (FCHN)
State Farm Insurance
Sterling Basic Plus
Sterling Medicare Select
Sterling Option 1/ Option 2
Superior Vision
TPM Trust
TPSC
Tricare
Tricare For Life
Trusteed Plans (FCHN)
UFCW Welfare Trust (FCHN)
Uniform Medical Plan
United Healthcare
VSP
WA/ID Carpenters-Employers Health
Washington Employers Trust (FCHN)
Wausau Benefits
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:
Employer/School:
Medical History
Please list any medical condition that you are currently being treated for: (Diabetes, HBP, Arthritis, Asthma, Heart , Seizures, Thyroid etc)
Please list any eye condition that you have had: (Injuries, Infections, Surgeries, Diseases etc)
Medications you are currently taking:
Occupation:
Employer:
Date of Birth:
Age:
Allergies:
Injuries, Surgeries, Hospitalizations:
Primary Care Physician:
Are you currently using any eye medications:
Last Eye Exam:
1 year
2 years
3 years
never
years ago
cannot remember
Last Eye Doctor:
Hobbies:
Please list your family medical history: (Diabetes,HBP,Arthritis,Thyroid etc)
Please list your family eye history: (Glaucoma,Cataract,Macular Deg.,Lazy Eye etc)
Are you interested in Lasik?
Do you use a computer?
Hours Per Day
Interested In CL
New Wearer
Previous Wearer
soft
soft toric
rgp
soft mono/bi
How often do you replace your lenses?
What lens solution do you use?
Opti-free
Biotrue
Clear Care
Renu
Complete
Boston
Generic
Aquify
Submit Data
After Completing All Forms Submit Data on Final Tab