Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. Fr. 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:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		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 the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. 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:

Medical Insurance

Insurance Information

Insurance Name:	None AARP Aetna Aetna Vision One Disc. All State Allied Benefit Systems, Inc. Always Vision American Continental Ins. Co American Public Life Insurance Company Amerigroup: Can't take! Ameritas Assurant Healthcare Avesis Avesis Medicare Bankers Life and Casualty Company Beechstreet (PAI) Block Vision Blue Choice: Can't take! Blue Cross Blue Shield Blue Cross Blue Shield Care First: Can't take! BMA Boon-Chapman Boon Group Bravo: Can't take! BUPA (UHC International) Care Improvement Plus Celtic: Can't take! Champva Christian Brothers Cigna Cigna *Starbridge* Cigna HMO: Can't take! Cigna International Cigna Local Plus IN: Can't Take! Cigna Network: Can't take! Community Health Choice Coventry Health Care Coventry Health Care of Georgia, Inc. Davis Vision Davis Vision Affinity Disc. Dongbu Insurance Co., Ltd Entrust Euro Center USA European Benefits Administrators Evercare: Can't take! EyeMed Eyemed: Can't take this plan! Eymed Disc. First Health Fiserv Health FlexMED FMH Benefit Services Fox-Everett GEHA Golden Rule Great West Healthcare-Cigna Group & Pension Admin Guardian Life Ins. Co. Health First Health Springs: Can't take! HealthEZ Healthsmart Hometown Health Humana Humana Medicare HMO: Can't take! Humana One Humana Vision: Can't take! Knust-SBO Loyal American M-Health: Can't take! Mail Handlers Medicaid Medicaid - Texas Women's Health Plan: Can't Take!!! Medicare - Medicare Medicare - Railroad - Medicare Mediplus MEGA Life & Health Ins. Meritain Health MES Vision Met Life Mid-West National Life Ins. Molina:Can't take! Multiplan Mutual of Omaha MVP NALC National Vision Administrators New York Life OHV Disc: Exam only w/disc. on materials! Opticare Optum Health Vision/ Spectera other insurance Oxford Health Pacificare Physicians Mutual PPO Next Principal Private Health Care Systems Provident American Life & Health Ins. Reserve National Samba Secure Horizons Security Life Ins. Co. Smith Administrators Southern Operators SRC Starmark Superior Vision Plan Texan Plus HMO: Can't take! Texas Children's Health Ins. Plan: Can't take! Texas STAR: Can't take! TML Tower Life Ins. Co. Transamerica Life Ins. Co. Tricare Tricare HMO: Can't take! Tricare Prime: Can't take! Trustmark UMR Unicare United American Insurance Company United Health Care United Health Care - Medicaid: Can't Take! United Health Care Integrated Services United Healthcare Shared Services USAA Life Ins. Co. Vision Service Plan WEB-TPA Well Care HMO: Can't Take! Wells Fargo TPA
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:

Vision Insurance

Insurance Information

Insurance Name:	None AARP Aetna Aetna Vision One Disc. All State Allied Benefit Systems, Inc. Always Vision American Continental Ins. Co American Public Life Insurance Company Amerigroup: Can't take! Ameritas Assurant Healthcare Avesis Avesis Medicare Bankers Life and Casualty Company Beechstreet (PAI) Block Vision Blue Choice: Can't take! Blue Cross Blue Shield Blue Cross Blue Shield Care First: Can't take! BMA Boon-Chapman Boon Group Bravo: Can't take! BUPA (UHC International) Care Improvement Plus Celtic: Can't take! Champva Christian Brothers Cigna Cigna *Starbridge* Cigna HMO: Can't take! Cigna International Cigna Local Plus IN: Can't Take! Cigna Network: Can't take! Community Health Choice Coventry Health Care Coventry Health Care of Georgia, Inc. Davis Vision Davis Vision Affinity Disc. Dongbu Insurance Co., Ltd Entrust Euro Center USA European Benefits Administrators Evercare: Can't take! EyeMed Eyemed: Can't take this plan! Eymed Disc. First Health Fiserv Health FlexMED FMH Benefit Services Fox-Everett GEHA Golden Rule Great West Healthcare-Cigna Group & Pension Admin Guardian Life Ins. Co. Health First Health Springs: Can't take! HealthEZ Healthsmart Hometown Health Humana Humana Medicare HMO: Can't take! Humana One Humana Vision: Can't take! Knust-SBO Loyal American M-Health: Can't take! Mail Handlers Medicaid Medicaid - Texas Women's Health Plan: Can't Take!!! Medicare - Medicare Medicare - Railroad - Medicare Mediplus MEGA Life & Health Ins. Meritain Health MES Vision Met Life Mid-West National Life Ins. Molina:Can't take! Multiplan Mutual of Omaha MVP NALC National Vision Administrators New York Life OHV Disc: Exam only w/disc. on materials! Opticare Optum Health Vision/ Spectera other insurance Oxford Health Pacificare Physicians Mutual PPO Next Principal Private Health Care Systems Provident American Life & Health Ins. Reserve National Samba Secure Horizons Security Life Ins. Co. Smith Administrators Southern Operators SRC Starmark Superior Vision Plan Texan Plus HMO: Can't take! Texas Children's Health Ins. Plan: Can't take! Texas STAR: Can't take! TML Tower Life Ins. Co. Transamerica Life Ins. Co. Tricare Tricare HMO: Can't take! Tricare Prime: Can't take! Trustmark UMR Unicare United American Insurance Company United Health Care United Health Care - Medicaid: Can't Take! United Health Care Integrated Services United Healthcare Shared Services USAA Life Ins. Co. Vision Service Plan WEB-TPA Well Care HMO: Can't Take! Wells Fargo TPA
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:

Other Insurance

Insurance Information

Insurance Name:	None AARP Aetna Aetna Vision One Disc. All State Allied Benefit Systems, Inc. Always Vision American Continental Ins. Co American Public Life Insurance Company Amerigroup: Can't take! Ameritas Assurant Healthcare Avesis Avesis Medicare Bankers Life and Casualty Company Beechstreet (PAI) Block Vision Blue Choice: Can't take! Blue Cross Blue Shield Blue Cross Blue Shield Care First: Can't take! BMA Boon-Chapman Boon Group Bravo: Can't take! BUPA (UHC International) Care Improvement Plus Celtic: Can't take! Champva Christian Brothers Cigna Cigna *Starbridge* Cigna HMO: Can't take! Cigna International Cigna Local Plus IN: Can't Take! Cigna Network: Can't take! Community Health Choice Coventry Health Care Coventry Health Care of Georgia, Inc. Davis Vision Davis Vision Affinity Disc. Dongbu Insurance Co., Ltd Entrust Euro Center USA European Benefits Administrators Evercare: Can't take! EyeMed Eyemed: Can't take this plan! Eymed Disc. First Health Fiserv Health FlexMED FMH Benefit Services Fox-Everett GEHA Golden Rule Great West Healthcare-Cigna Group & Pension Admin Guardian Life Ins. Co. Health First Health Springs: Can't take! HealthEZ Healthsmart Hometown Health Humana Humana Medicare HMO: Can't take! Humana One Humana Vision: Can't take! Knust-SBO Loyal American M-Health: Can't take! Mail Handlers Medicaid Medicaid - Texas Women's Health Plan: Can't Take!!! Medicare - Medicare Medicare - Railroad - Medicare Mediplus MEGA Life & Health Ins. Meritain Health MES Vision Met Life Mid-West National Life Ins. Molina:Can't take! Multiplan Mutual of Omaha MVP NALC National Vision Administrators New York Life OHV Disc: Exam only w/disc. on materials! Opticare Optum Health Vision/ Spectera other insurance Oxford Health Pacificare Physicians Mutual PPO Next Principal Private Health Care Systems Provident American Life & Health Ins. Reserve National Samba Secure Horizons Security Life Ins. Co. Smith Administrators Southern Operators SRC Starmark Superior Vision Plan Texan Plus HMO: Can't take! Texas Children's Health Ins. Plan: Can't take! Texas STAR: Can't take! TML Tower Life Ins. Co. Transamerica Life Ins. Co. Tricare Tricare HMO: Can't take! Tricare Prime: Can't take! Trustmark UMR Unicare United American Insurance Company United Health Care United Health Care - Medicaid: Can't Take! United Health Care Integrated Services United Healthcare Shared Services USAA Life Ins. Co. Vision Service Plan WEB-TPA Well Care HMO: Can't Take! Wells Fargo TPA
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

Reason For Visit Today:



PATIENT OCULAR HISTORY:

Last Eye Exam: 1 yr 2 yrs 5 yrs 10+ yrs <6 mos never Other

Ocular Allergies:	no yes mild moderate severe chronic Other	Eye Infections:	no yes "pink eye" stye Other	Glaucoma:	no yes suspect POAG Other	Flashes / Floaters:	no floaters only flashes only stable Other
Dry Eyes:	no yes chronic mild severe Other	Eye injury:	no yes Other	Cataracts:	no yes OD OS OU Other	Retinal Detachment:	no yes OD OS OU Other
Double Vision:	no OD OS Other	Eye Sugery:	no cataract LASIK Pterygium PRK RK Other	Macular Degeneration:	no yes mild severe dry wet stable Other	Eye Turn / Lazy:	no yes OD OS OU Other

Other:



PATIENT MEDICAL HISTORY:

Last Physical Exam: 1 yr 2 yrs 5 yrs 10+ yrs <6 mos none unknown Other

Hypertension:	no yes controlled not controlled fluctuates Other	High Cholesterol:	no yes stable fluctuates Other	Thyroid:	no yes hyper hypo stable not controlled Other	Allergies / Sinus:	no yes chronic mild severe Other
Diabetes:	no type 1 type 2 controlled not controlled borderline diet controlled Other	Cancer:	no yes Other	Arthritis:	no yes stable chronic Other	HA / Migraine:	no yes chronic Other
Cardiovascular:	no yes heart attack stroke bypass Other	Autoimmune:	no yes Lupus RA Other	Asthma:	no yes chronic Other	Pregnant / Nursing:	no yes nursing only Other

Other:



FAMILY MEDICAL HISTORY:

Glaucoma:	no mom dad brother sister siblings grandparents gm gf ggm ggf uncle aunt maternal side paternal side Other	Macular Degeneration:	no mom dad brother sister siblings grandparents gm gf ggm ggf uncle aunt maternal side paternal side Other	Diabetes:	no mom dad brother sister siblings grandparents gm gf ggm ggf uncle aunt maternal side paternal side Other	Hypertension:	no mom dad brother sister siblings grandparents gm gf ggm ggf uncle aunt maternal side paternal side Other
Cataracts:	no mom dad brother sister siblings grandparents gm gf ggm ggf uncle aunt maternal side paternal side Other	Retinal Disease:	no mom dad brother sister siblings grandparents gm gf ggm ggf uncle aunt maternal side paternal side Other	Cancer:	no mom dad brother sister siblings grandparents gm gf ggm ggf uncle aunt maternal side paternal side Other	Cardiovascular:	no mom dad brother sister siblings grandparents gm gf ggm ggf uncle aunt maternal side paternal side Other

Other:



MEDICATIONS:


DRUG ALLERGIES:


SOCIAL HISTORY

Alcohol
Tobacco
Drugs

Age:
Occupation:
Race:	Caucasian Asian Hispanic or Latino Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other
Preferred Language:	English Spanish Vietnamese French German Other

Submit Data / Patient Signatures

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

Consent Form

ADDITIONAL TESTING: (We strongly recommend these procedures for all ages, especially those over 40.)

Dilated Fundus Exam: With the use of eye drops, the pupils become enlarged allowing the doctor a more thorough view of the retina. Dilation is essential for patients with a history of diabetes, high blood pressure, cholesterol, glaucoma, macular degeneration, cataracts, a strong prescription, or any family history of eye diseases. Side effects include blurred near vision and light sensitivity for about 4-6 hours.
The fee for this test is $15.00. (Paid for by all insurance.)

Optomap and OCT Retinal Exams: These retinal cameras provide images and cross-sectional views of the retina which can be used to detect many diseases as diabetes, high blood pressure, glaucoma, macular degeneration, and many retinal diseases. They are also very useful for documentation for future comparison. It can replace the traditional dilated fundus exam and has no side effects. The fee for these tests is $49.00. (Paid for by most medical insurance if a medical diagnosis exists.)
*Please initial next to chosen option below.

I would like to have the traditional dilated exam performed.
I would like to have the Optomap and OCT retinal exams instead of the traditional dilated exam.
I decline all procedures and release Hoa Nguyen, OD & Associates from all liability related to the failure to treat and diagnose any eye condition due to the lack of diagnostic information that could have been obtained.

Visual Field Test: A computerized instrument will be used to screen for any blind spots in your central and peripheral vision. Visual field testing can assist in the early detection of glaucoma, retinal problems, and some neurological diseases such as brain tumors and optic nerve diseases. It can also enable us to better diagnose causes of headaches. The fee for this test is $15.00. (Paid for by most medical insurance if a medical diagnosis exists.)
*Please initial next to chosen option below.

I would like to have the visual field test performed.
I decline and release Hoa Nguyen, OD & Associates from all liability related to the failure to treat and diagnose any eye condition due to the lack of diagnostic information that could have been obtained.

INSURANCE AUTHORIZATION: I authorize my insurance benefits to be paid directly to Dr. Hoa T. Nguyen and understand that I am financially responsible for any non-covered or denied services.
Patient / Parent Initials:

HIPAA NOTICE OF PRIVACY PRACTICES: I acknowledge that I have been presented with and had full opportunity to read the HIPAA Notice of Privacy Practices attachment.
Patient / Parent Initials:

Patient / Parent Signature: Date:

AUTHORIZATION TO DISCLOSE INFORMATION

I, , hereby authorize Ocular Oasis (Dr. Hoa T. Nguyen) to disclose the protected health information described below to:

Name Of Person To Whom The Information Is To Be Disclosed To      Relationship To Person Giving Consent

               
               
               
               

Information to be disclosed (initial next to ALL or check ONLY those that apply):

ALL (I choose to disclose ALL of the information listed below):

	Medical Records		Prescription Information
	Treatment Records		Billing Information
	Diagnostic Records		Insurance Information

This medical information may be used by the person/ persons I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

This authorization is valid until the earlier of the occurrence of the death of the individual; or permission is withdrawn; or the following specific date (optional):

I may revoke this authorization in writing at any time by sending written notification to Hoa T. Nguyen OD at 1830 S. Mason Rd, Ste 130, Katy, TX 77450. This notice will not apply to actions taken by the requesting person/entity prior to the date they received the written request to revoke authorization.

I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Signature: Date:

**If representative, specify relationship to the individual:

** By entering my First and Last name, I understand, agree and accept that I am constituting a legally binding electronic signature which I
        accept has the same validity and meaning as my handwritten signature.