New Patient Form

Demographics

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

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:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Maynard, Gretchen L Dr. C/L Teach, Dr. Streiff, Lavender Dr. Galina, Nikolova V	Misc/Guardian
How Did You Hear About Us?	Family/Friend Insurance Physician School Nurse Social Media-Facebook Website

Billing Information

Is The Billing Address the Same?

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

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 Vision

Insurance Information

Insurance Name:	None Eyemed Vision Vision Service 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:
Employer/School:

Secondary Vision

Insurance Information

Insurance Name:	None Eyemed Vision Vision Service Plan
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 Aetna Aetna Better Health AETNA LIFE INSURANCE COMPANY All Savers Allied Benefit System Inc. BCBS-Medicare Advantage Blue Cross Blue Shield Blue Cross Blue Shield Community Health Plans Blue Cross Blue Shield FHP Blue Cross Community MMAI Bright Health Care CGS - Jurisdiction B Claims Cigna Community Vision Care County Care FHP Devoted Health Plans Family Health Network Golden Rule Insurance Company Health Link HMO Humana Illinicare Illinois Medicaid KOVACH EYE INSTITUTE LASIK PLUS Local 502 Cement Masons Local 705 IBT H&W Fund Manhattan Life Insurance MBA Limited Medical Medicare IL Meridian Health Plan Meritain Health Mutual of Omaha Nippon Life Insurance Company of America Oxford Health Plans PRIVATE INSURANCE Rail Road Medicare Sana Benefits Sentinel Security Life Ins Sierra Health and Life Insurance Company, Inc. Supplemental Medicare Wraparound Plus Program Thrivent Financial TLC Vision Tricare East Region Claims UMR United Health Care United Healthcare Student Resources Workers Compensation
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 Medical

Insurance Information

Insurance Name:	None Aetna Aetna Better Health AETNA LIFE INSURANCE COMPANY All Savers Allied Benefit System Inc. BCBS-Medicare Advantage Blue Cross Blue Shield Blue Cross Blue Shield Community Health Plans Blue Cross Blue Shield FHP Blue Cross Community MMAI Bright Health Care CGS - Jurisdiction B Claims Cigna Community Vision Care County Care FHP Devoted Health Plans Family Health Network Golden Rule Insurance Company Health Link HMO Humana Illinicare Illinois Medicaid KOVACH EYE INSTITUTE LASIK PLUS Local 502 Cement Masons Local 705 IBT H&W Fund Manhattan Life Insurance MBA Limited Medical Medicare IL Meridian Health Plan Meritain Health Mutual of Omaha Nippon Life Insurance Company of America Oxford Health Plans PRIVATE INSURANCE Rail Road Medicare Sana Benefits Sentinel Security Life Ins Sierra Health and Life Insurance Company, Inc. Supplemental Medicare Wraparound Plus Program Thrivent Financial TLC Vision Tricare East Region Claims UMR United Health Care United Healthcare Student Resources Workers Compensation
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 Medical

Insurance Information

Insurance Name:	None Aetna Aetna Better Health AETNA LIFE INSURANCE COMPANY All Savers Allied Benefit System Inc. BCBS-Medicare Advantage Blue Cross Blue Shield Blue Cross Blue Shield Community Health Plans Blue Cross Blue Shield FHP Blue Cross Community MMAI Bright Health Care CGS - Jurisdiction B Claims Cigna Community Vision Care County Care FHP Devoted Health Plans Family Health Network Golden Rule Insurance Company Health Link HMO Humana Illinicare Illinois Medicaid KOVACH EYE INSTITUTE LASIK PLUS Local 502 Cement Masons Local 705 IBT H&W Fund Manhattan Life Insurance MBA Limited Medical Medicare IL Meridian Health Plan Meritain Health Mutual of Omaha Nippon Life Insurance Company of America Oxford Health Plans PRIVATE INSURANCE Rail Road Medicare Sana Benefits Sentinel Security Life Ins Sierra Health and Life Insurance Company, Inc. Supplemental Medicare Wraparound Plus Program Thrivent Financial TLC Vision Tricare East Region Claims UMR United Health Care United Healthcare Student Resources Workers 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:

Medical History

Medical History: Diabetes, High blood pressure, Heart Disease, Thyroid Disease, Kidney Disease, Arthritis, Asthma, Cancer, Stroke, Seizures, Heart Condition, Other

Good Health Diabetes High blood pressure Heart Disease Thyroid Disease Kidney Disease Arthritis Asthma Cancer Stroke Heart Condition HIV HTN Hx of Drug/Alcohol Abuse Seizures Seizures Seizures Inflammatory Bowel Disease Lupus Seizure Disorder Other

Ocular History: Glaucoma, Macular degeneration, Cataract, Retinal detachment, Crossed/lazy eye, Injury, Surgery

*None Allergic Conj Amblyopia Blepharitis Cataracts Floaters Glc suspect Macular Degeneration NTG POAG Strabismus

Injuries, Surgeries, Hospitalizations:

*None Injury Hospitalization Surgery

Family Medical History:

Good health Arthritis Asthma Cancer Diabetes Heart Condition HIV HTN HX Of Drug/Alcohol Abuse Inflammatory Bowel Disease Kidney disease Lupus Seizure Disorder Stroke Thyroid Disease

Family Ocular History:

None Glaucoma Macular degeneration Cataract Retinal detachment Crossed/lazy eye Unknown

General Practitioner:

Pregnant/Nursing:

*No Yes Unsure

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Medications (Prescribed):

*None Actos Acyclovir Adderall Albuterol Allegra Altase Amaryl Amiodarone Amoxycillin Atenolol Augmentin Bactroban Buspar Captopril Carbamazepine Cefzil Celebrex Cipro Clonidin Coumadin Cozar Crestor Depakote Detrol Diclofenac Dilantin Diovan Effexor Flomax Flonase Furosamide Glucophage Glyburide HCTZ Humulin Hydrocortisone Lasix Levaquin Lipitor Lortab Metformin Methylprednisolone MC Contin Nasacort Novalog Oxycodone Pepcid Plaquenil Plavix Prednisone Premarin Prempro Protonix Proventil Prozac Ritalin Singulair Synthroid Tetracycline Topomax Valium Wellbutrin Xanax Zantax Zestril Zoloft Other

Over-The-Counter Medications:

*None Acetomenophin Allegra Aspirin Ibuprofen Zyrtec Other

Vitamins:

*None A C E Lutein Multi Omega 3 Zinc Other

Eye Meds:

*None Alphagan Artificial Tears Pataday Travatan Visine Xalatan Other

Drug Allergies:

Primary Vision Correction:

*None GlassesFTW GlassesDVO GlassesNVO Contacts-Soft Contacts-RGP

Last Eye Exam:

*1 year <1 year 2 year 3 years

Sunglasses?

*Yes No

Type of CLs:

*None Soft Sphere Soft toric Soft bifocal RGP-single vision RGP-bifocal

Occupation:

Hobbies:

*None listed Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint None Painting Photography Piano Reading Running Rollerblading Softball Sewing Skiing Soccer Swimming Tennis Video Games Woodworking

REVIEW OF SYSTEMS-Please document if you currently have or previously had any of the following: CONSTITUTIONAL:

*None Fatigue Fever Night Sweats Weight Gain Weight Loss

EYES:

*None Blur Double Vision Floaters Flashes Glare Distortion Tear Burn Itch Dry Red Pain Light Sensitive

EAR/NOSE/THROAT:

*None Allergies Sinus Problems Chronic Cough Dry Throat/Mouth Hard of Hearing

CARDIO:

*None High BP Chest Pain Irregular Heartbeat/palpitations Blood Clot

RESPIRATORY:

*None Asthma Bronchitis Emphysema COPD

GASTRO-INTESTINAL:

*None Constipation Diarrhea Hernia Ulcers Vomiting

REPRODUCTIVE/URINARY:

*None Bladder Issues Impotence Kidney Problems Urination-frequent Urination-painful

MUSCULOSKELETAL:

*None Joint Pain Joint Swelling Muscle Pain Muscle Weakness Rheumatoid Arthritis

SKIN:

*None Acne Eczema Growths Rash

NEURO:

*None Dizzy Gait Disturbance Headache Migraines Numb Seizures

PSYCH:

*None Anxiety Depression Insomnia

ENDOCRINE:

*None Diabetes Hyperthyroid Hypothyroid

BLOOD/LYMPH:

*None Anemia bruise/bleed easily Hypercholesterolemia

IMMUNOLOGIC:

*None AIDS HIV Lupus Rheumatoid Arthritis

SOCIAL HISTORY: Race:

*Alaskan Native American Indian or Alaska Native American Indian/Alaskan Native, Asian Black or African American Black/African American (Not Hispanic) Greek Hawaiian Not Hispanic Greek Hawaiian Hispanic Hispanic or Latino (All Races) Indian More than one race Multi-racial Native American Indian Native Hawaiian or Other Pacific Islander Other Pacific Islander (Not Hawaiian) Other Race Unknown/Not Reported White White (Not Hispanic/Latino) Declined

Ethnicity:

*Hispanic or Latino Not Hispanic or Latino Unknown Ethnicity Declined

Language

*English Spanish Polish Arabic Bulgarian Cambodian Cantonese Central Khmer Chinese French German Haitian; Haitian Creole Hebrew Hindi Italian Japanese Korean Mandarin Portuguese Russian Somali Spanish; Castilian Swahili Thai Urdu Vietnamese Declined

Height: Feet Inches

Weight:

Alcohol:

*No Yes Occasionally Socially

Tobacco:

*never smoker former smoker current every day smoker current some day smoker smoker (current status unknown) unknown if ever smoked Yes

Illegal Drugs

*No Yes

Patient Signatures

Medical Insurance Information

PPO Medical Insurance Company Name:
Primary Member Name: Primary Member Date Of Birth:

Financial and Insurance Policies

• The vision and medical insurance information I have provided Bensenville Eye Care is current and accurate.
• I am responsible for notifying Bensenville Eye Care prior to my visit with any changes to my insurances.
• The professional services I receive at Bensenville Eye Care will be based on my eye care needs and wants. The appropriate insurance will thus be billed. If I have medical eye conditions addressed, my medical insurance will be billed. If I am receiving a routine vision exam, my vision insurance (or if I have routine coverage through my medical insurance) will be billed. Sometimes my insurance benefits can be coordinated so portions can go to my medical insurance AND portions can go to my vision insurance.
• I understand that vision insurances (eg. VSP, EyeMed) ONLY cover routine vision exams/testing and any other eye issues/diagnoses/emergencies (eg. diabetes, cataracts, dry eye) are considered medical in nature and will be billed to my medical insurance.
• I authorize Bensenville Eye Care to submit all pertinent information to my insurance companies and act as my agent to help me maximize my insurance benefits as I receive individualized eye care.
• I authorize payment directly to Bensenville Eye Care.
• Bensenville Eye Care will make every effort to accurately quote and preauthorize insurance benefits on my behalf; however I understand that any discussion of insurance benefits by Bensenville Eye Care is an estimation only and not a guarantee of payment by an insurance company. Coverage and eligibility is solely determined by the insurance company.
• Any questions regarding my coverage, eligibility and benefits (payment) must be communicated by me directly with my insurance carrier, as I hold the contract with that company.
• If my insurance company requires a referral for my visit (HMO insurance), I am responsible for making that determination and making sure that referral is completed by the time of service. If this is not done, I may be personally responsible for the services rendered.
• All insurance co-pays and deductibles must be paid at the time of service.
• I understand that I am responsible for payment to Bensenville Eye Care on any claims that are 1) applied to deductible or co-insurance; 2) denied; 3) partially paid; 4) partially paid specifically due to the carrier’s arbitrary determination of usual and customary rates; 5) beyond 120 days. If my insurance does not pay the claim timely, it is expected that I will get involved to help resolve my insurance claim and pay the outstanding balance with Bensenville Eye Care in full while insurance delays payment. If an insurance payment is received after my payment in full, a refund will be issued according to Bensenville Eye Care’s credits policy.
• I permit a copy of this authorization to be used in place of the original.
• If I miss, cancel or reschedule an appointment with less than 24 hours of notice, I understand there will be a $39 fee.
• For returned checks due to non-sufficient funds, I understand there will be a $39 service fee.

Acknowledgements and Consent for Treatment

• I have read and acknowledge the above Financial and Insurance Policies.
• I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care and appropriate billing.
• I consent to the doctor’s or designated staff’s use and disclosure of any oral, written, or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment, and health care options.
• I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.

Patient Name: Date:
Patient's Signature (or Parent/Guardian):

Acknowledgement of HIPAA Receipt

I acknowledge that I received a copy of Bensenville Eye Care’s Notice of Privacy Practices (attached). This notice describes how Bensenville Eye Care may use and disclose my protected health information, certain restrictions on the use and disclosure of my health care information, and rights I may have regarding my protected health information.

Patient Name: Date:
Patient's Signature (or Parent/Guardian):

Credit Card on File Authorization for Payment of Patient Balance

Terms
Effective Date: Date of Service and/or Date of Goods Purchased
Expiration Date: 1 Year from Date of Service and/or Date of Goods Purchased

I agree to allow Bensenville Eye Care to charge my credit card on file for the balance not covered by my insurance(s) for all services received and/or goods purchased. I acknowledge that:

• Upon review of the final explanation of benefits from each applicable insurance company, Bensenville Eye Care will issue an invoice to me for any remaining balance.
• If payment is not received within 14 days, my credit card on file will be charged the remaining balance and I will receive an emailed receipt.
• My credit card information will be stored in the CardPointe Gateway by USIO, Inc, a secure credit card processor that partners with Bensenville Eye Care to collect payments and keep all patient data secure.

Cardholder E-Signature Date

Informacion de Seguro

Nombre de la compania de seguro medico PPO:
Nombre de miembro primario: Fecha de nacimiento del miembro primario:

Politicas Financieras y de Seguros

• La información sobre el seguro médico y de la vista que he proporcionado a Bensenville Eye Care está actualizada y es precisa.
• Soy responsable de notificar a Bensenville Eye Care antes de mi visita cualquier cambio en mis seguros.
• Los servicios profesionales que recibo en Bensenville Eye Care se basarán en mis necesidades y deseos de atención oftalmológica. De este modo se facturará el seguro correspondiente. Si tengo problemas médicos oculares tratados, se facturará a mi seguro médico. Si me someto a un examen de la vista de rutina, se facturará a mi seguro de la vista (o si tengo cobertura de rutina a través de mi seguro médico). A veces, los beneficios de mi seguro se pueden coordinar para que partes puedan ir a mi seguro médico Y partes puedan ir a mi seguro de la vista.
• Entiendo que los seguros de la vista (p. ej., VSP, EyeMed) SÓLO cubren exámenes/pruebas de la vista de rutina y cualquier otro problema/diagnóstico/emergencia ocular (p. ej., diabetes, cataratas, ojo seco) se consideran de naturaleza médica y se facturarán a mi seguro médico.
• Autorizo a Bensenville Eye Care a enviar toda la información pertinente a mis compañías de seguros y actuar como mi agente para ayudarme a maximizar los beneficios de mi seguro a medida que recibo atención oftalmológica individualizada.
• Autorizo el pago directamente a Bensenville Eye Care.
• Bensenville Eye Care hará todo lo posible para cotizar con precisión y preautorizar los beneficios del seguro en mi nombre; sin embargo, entiendo que cualquier discusión sobre los beneficios del seguro por parte de Bensenville Eye Care es solo una estimación y no una garantía de pago por parte de una compañía de seguros. La cobertura y la elegibilidad están determinadas únicamente por la compañía de seguros.
• Cualquier pregunta sobre mi cobertura, elegibilidad y beneficios (pago) debo comunicarla directamente a mi compañía de seguros, ya que tengo contrato con esa compañía.
• Si mi compañía de seguros requiere una remisión para mi visita (seguro HMO), soy responsable de tomar esa determinación y asegurarme de que la remisión se complete antes del momento del servicio. Si no se hace esto, puedo ser personalmente responsable de los servicios prestados.
• Todos los copagos y deducibles del seguro deben pagarse en el momento del servicio.
• Entiendo que soy responsable del pago a Bensenville Eye Care por cualquier reclamo que 1) se aplique al deducible o coseguro; 2) negado; 3) parcialmente pagado; 4) parcialmente pagado específicamente debido a la determinación arbitraria de las tarifas habituales y acostumbradas por parte del transportista; 5) más allá de 120 días. Si mi seguro no paga el reclamo a tiempo, se espera que participe para ayudar a resolver mi reclamo de seguro y pagar el saldo pendiente con Bensenville Eye Care en su totalidad mientras el seguro retrasa el pago. Si se recibe un pago de seguro después de mi pago completo, se emitirá un reembolso de acuerdo con la política de créditos de Bensenville Eye Care.
• Autorizo que se utilice una copia de esta autorización en lugar del original.
• Si pierdo, cancelo o reprogramo una cita con menos de 24 horas de aviso, entiendo que habrá un cargo de $39.
• Para cheques devueltos debido a fondos insuficientes, entiendo que habrá un cargo de servicio de $39.

Reconocimientos y Consentimiento para Tratamiento

• He leído y acepto las pólizas financieras y de seguros mencionadas anteriormente.
• Autorizo al médico para que realice todo el tratamiento recomendado que haya acordado mutuamente y que emplee la asistencia necesaria para proporcionar la atención adecuada.
• Doy mi consentimiento para que el médico o el personal designado usen y divulguen cualquier registro de salud oral, escrito o electrónico que sea identificable individualmente como mío con el fin de llevar a cabo mi tratamiento, pago y opciones de atención médica.
• Certifico que leí o me lo leyeron el contenido de este formulario y me doy cuenta de los riesgos y limitaciones que implica. Nombre del paciente: Fecha:
Firma del paciente (o padre/tutor):

Reconocimiento de recibo de HIPAA

Reconozco que recibí una copia del Aviso de prácticas de privacidad de Bensenville Eye Care (adjunto). Este aviso describe cómo Bensenville Eye Care puede usar y divulgar mi información de salud protegida, ciertas restricciones en el uso y divulgación de mi información de atención médica y los derechos que puedo tener con respecto a mi información de salud protegida.

Nombre del paciente: Fecha:
Firma del paciente (o padre/tutor):


Tarjeta de crédito registrada Autorización para el pago del saldo del paciente
Términos
Fecha de Vigencia: Fecha del Servicio y/o Fecha de los Bienes Adquiridos.
Fecha de Vencimiento: 1 Año a Partir de la Fecha del Servicio y/o Fecha de Compra de los Bienes
Acepto permitir que Bensenville Eye Care cargue en mi tarjeta de crédito registrada el saldo no cubierto por mi(s) seguro(s) por todos los servicios recibidos y/o bienes comprados. Yo reconozco que:
• Tras revisar la explicación final de los beneficios de cada compañía de seguros aplicable, Bensenville Eye Care me emitirá una factura por el saldo restante.
• Si el pago no se recibe dentro de los 14 días, se cargará el saldo restante a mi tarjeta de crédito registrada y recibiré un recibo por correo electrónico.
• La información de mi tarjeta de crédito será almacenada en CardPointe Gateway por USIO, Inc, un procesador seguro de tarjetas de crédito que se asocia con Bensenville Eye Care para cobrar pagos y mantener seguros todos los datos del paciente.

Nombre Impreso del Titular de la Tarjeta: Fecha