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:
Cell Phone:		Email
SSN		Occupation
Birthday		Employment Status	Employed Full-Time Student Part-Time Student
Sex	Male Female	Employer/School Name
Marital Status	Single Married Separated Divorced Widowed Unknown	Misc/Guardian
Primary Eye Doctor	No Doctor Assigned Dr. Maynard, Gretchen L Dr. Streiff, Lavender

How Did You Hear About Us?

Family/Friend Insurance Physician School Nurse Social Media-Facebook Website

Name of Family/Friend Who Referred You to Us?

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:
SSN:
Employer/School:

Secondary 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:
SSN:
Employer/School:

Primary Medical

Insurance Information

Insurance Name:	None Aetna All Savers Allied Benefit System Inc. BCBS-Medicare Advantage Blue Cross Blue Shield Blue Cross Blue Shield FHP Bright Health Care CGS - Jurisdiction B Claims Cigna Devoted Health Plans Family Health Network Golden Rule Insurance Company Health Link HMO Humana Local 502 Cement Masons Local 705 IBT H&W Fund Manhattan Life Insurance MBA Limited Medical Medicare IL Meritain Health Mutual of Omaha Nippon Life Insurance Company of America Oxford Health Plans OTHER 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 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:
SSN:
Employer/School:

Secondary Medical

Insurance Information

Insurance Name:	None Aetna All Savers Allied Benefit System Inc. BCBS-Medicare Advantage Blue Cross Blue Shield Blue Cross Blue Shield FHP Bright Health Care CGS - Jurisdiction B Claims Cigna Devoted Health Plans Family Health Network Golden Rule Insurance Company Health Link HMO Humana Local 502 Cement Masons Local 705 IBT H&W Fund Manhattan Life Insurance MBA Limited Medical Medicare IL Meritain Health Mutual of Omaha Nippon Life Insurance Company of America Oxford Health Plans OTHER 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 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:
SSN:
Employer/School:

Tertiary Medical

Insurance Information

Insurance Name:	None Aetna All Savers Allied Benefit System Inc. BCBS-Medicare Advantage Blue Cross Blue Shield Blue Cross Blue Shield FHP Bright Health Care CGS - Jurisdiction B Claims Cigna Devoted Health Plans Family Health Network Golden Rule Insurance Company Health Link HMO Humana Local 502 Cement Masons Local 705 IBT H&W Fund Manhattan Life Insurance MBA Limited Medical Medicare IL Meritain Health Mutual of Omaha Nippon Life Insurance Company of America Oxford Health Plans OTHER 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 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:
SSN:
Employer/School:

Medical History

Medical History:

Good Health Allergies Anemia Asthma Cancer COPD Coronary artery disease Crohn's disease Diabetes Emphysema Heart condition HIV/AIDS High blood pressure High cholesterol HX of drug/alcohol abuse Inflammatory bowel disease Kidney disease Migraines Lupus Rheumatoid arthritis Seizures Stroke Thyroid disease Other

REVIEW OF SYSTEMS: Please select all that apply to you (current or past) 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

Pregnant/Nursing:

*No Nursing Pregnant Unsure

General Practitioner:

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 Drops:

None Alphagan Artificial Tears Pataday Travatan Visine Xalatan Other

Drug Allergies: Please list medications and explain reactions

Injuries, Surgeries, Hospitalizations:

None Injury Hospitalization Surgery

Ocular History:

None Cataract Eye Turn/Lazy Eye Glaucoma Macular Degeneration Retinal Detachment Other

Last Eye Exam:

*1 year <1 year 2 year 3 years

Primary Vision Correction:

*None Glasses Contacts lenses

If wear contact lenses, what brand?

How often do you replace them?

Daily Weekly 2 Weeks Monthly Quarterly Annually

Do you sleep in them?

Yes No

List eye injuries or eye surgeries:

Do you wear sun protection for your eyes?

Yes No

Do you use a screen 3+ hours/day?

Yes No

Does your vision limit any of your preferred activities? (e.g. driving, reading, work, sports, hobbies)

Yes No

Family Medical History:

None Cancer Diabetes Heart Disease High Blood Pressure High Cholesterol Thyroid Disease

Family Ocular History:

None Blindess Eye Turn/Lazy Eye Glaucoma Macular degeneration Retinal detachment

Sports and Hobbies:

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

Alcohol:

*No Rarely Socially Weekends Daily

Smoke:

Never Occasional Daily

What Smoke?

Cigarettes Cigars E-cigarettes Marijuana Pipes

Illegal Drugs:

*No Yes

SOCIAL HISTORY: Race:

White Black or African American American Indian or Alaska Native Asian Indian Native Hawaiian or Other Pacific Islander More than one race Other race

Ethnicity:

Not Hispanic or Latino Hispanic or Latino

Preferred 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

Patient Signatures

Patient Agreement and Consent to Care

• 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.
• 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.
• 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 consent to receive text messages, phone calls, emails or other communications related to my eye care or account.
• I permit a copy of this authorization to be used in place of the original.

Acknowledgement of Patient Agreement and Consent to Care

• I have read and acknowledge the above Patient Agreement and Consent to Care.
• I certify that I do realize the risks and limitations involved in the contents of this form.

Patient Name: Date:
Typed Name is the Same as 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.

View HIPAA Form

Patient Name: Date:
Typed Name is the Same as Patient's Signature (or Parent/Guardian):