New Patient Form

Demographics

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	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Kats, Paul Dr. Chang, Amy	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
	IL 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:

View Patient Responsibility Disclosure Statement
Please bring your insurance card(s) on your visit that we may make a copy to complete your records.
I, the undersigned, certify that I (or my dependent) have insurance coverage with the above insurance and assign directly to Kats Eye Care,P.C. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. By signing this statement, I understand that my vision and/or health insurance coverage is a contract between myself and my insurance company. Although Dr. Kats and staff have made every effort to verify my benefits before my appointment, no guarantee can be made that the information received is accurate since incorrect information may be provided by my insurance company from time to time. I understand that it is ultimately my responsibility as the patient to understand my vision and/or health insurance coverage as well as handle any charges my plan does not cover.
* I have read and understand the Patient Responsibility Disclosure Statement. Initial: 

View HIPAA Privacy Policies
* I have been given the opportunity to read this practice's HIPAA Privacy Policies. Initial: 

Primary

Insurance Information

Insurance Name:	None Always Vision Avesis Block Vision Davis Vision ADVENTIST RISK MANAGEMENT ADVENTIST RISK MGMT ACTIV AETNA BETTER HEALTH AETNA BMO FINANCIAL GROUP U.S. BLUE CROSS BLUE SHIELD OF ILLINOIS BCBS CELTIC SPECIAL HEALTH CIGNA ALL PLANS CORESOURCE CORESOURCE CUSTOM DESIGN BENEFIT ICE00 EMPLOYEE BENEFIT MANAGEMENT SERVICE EBMS FIRST HEALTH NETWORK HEALTHEZ GREAT WEST HEALTH CARE HEALTH SMART GUARDIAN SUBURBAN LUNG HEALTHLINK HEALTHLINK HUMANA HUMANA CARE PLAN INSURANCE MANAGEMENT ADMINISTRATORS METRO AVIATION MEDICARE PART B MEGA LIFE AND HEALTH INSURANCE COMP MEGA INSURANCE MES Vision MUTUAL MEDICAL UNITED FACILITIES HEALTH CARE PLAN NVA Optum Health Vision PROFESSIONAL BENEFITS ADMINISTRATOR STERLING ENGINEERING. SELF INSURED SERVIVES COMPANY SISCO STATE OF ILLINOIS HEALTHCARE AND FAMILY SERVICES THE TBG BENEFIT GROUP THE BENEFIT GROUP UMR SYNERGY UNITED HEALTH CARE 911-87726-04 UNIVERSAL HEALTH CARE UNIVERSAL HEALTH CARE VSP Unknown Import
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

Insurance Information

Insurance Name:	None ADVENTIST RISK MANAGEMENT ADVENTIST RISK MGMT ACTIV AETNA BETTER HEALTH AETNA BMO FINANCIAL GROUP U.S. BLUE CROSS BLUE SHIELD OF ILLINOIS BCBS CELTIC SPECIAL HEALTH CIGNA ALL PLANS CORESOURCE CORESOURCE CUSTOM DESIGN BENEFIT ICE00 EMPLOYEE BENEFIT MANAGEMENT SERVICE EBMS FIRST HEALTH NETWORK HEALTHEZ GREAT WEST HEALTH CARE HEALTH SMART GUARDIAN SUBURBAN LUNG HEALTHLINK HEALTHLINK HUMANA HUMANA CARE PLAN INSURANCE MANAGEMENT ADMINISTRATORS METRO AVIATION MEDICARE PART B MEGA LIFE AND HEALTH INSURANCE COMP MEGA INSURANCE MUTUAL MEDICAL UNITED FACILITIES HEALTH CARE PLAN PROFESSIONAL BENEFITS ADMINISTRATOR STERLING ENGINEERING. SELF INSURED SERVIVES COMPANY SISCO STATE OF ILLINOIS HEALTHCARE AND FAMILY SERVICES THE TBG BENEFIT GROUP THE BENEFIT GROUP UMR SYNERGY UNITED HEALTH CARE 911-87726-04 UNIVERSAL HEALTH CARE UNIVERSAL HEALTH CARE Unknown Import
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

Insurance Information

Insurance Name:	None ADVENTIST RISK MANAGEMENT ADVENTIST RISK MGMT ACTIV AETNA BETTER HEALTH AETNA BMO FINANCIAL GROUP U.S. BLUE CROSS BLUE SHIELD OF ILLINOIS BCBS CELTIC SPECIAL HEALTH CIGNA ALL PLANS CORESOURCE CORESOURCE CUSTOM DESIGN BENEFIT ICE00 EMPLOYEE BENEFIT MANAGEMENT SERVICE EBMS FIRST HEALTH NETWORK HEALTHEZ GREAT WEST HEALTH CARE HEALTH SMART GUARDIAN SUBURBAN LUNG HEALTHLINK HEALTHLINK HUMANA HUMANA CARE PLAN INSURANCE MANAGEMENT ADMINISTRATORS METRO AVIATION MEDICARE PART B MEGA LIFE AND HEALTH INSURANCE COMP MEGA INSURANCE MUTUAL MEDICAL UNITED FACILITIES HEALTH CARE PLAN PROFESSIONAL BENEFITS ADMINISTRATOR STERLING ENGINEERING. SELF INSURED SERVIVES COMPANY SISCO STATE OF ILLINOIS HEALTHCARE AND FAMILY SERVICES THE TBG BENEFIT GROUP THE BENEFIT GROUP UMR SYNERGY UNITED HEALTH CARE 911-87726-04 UNIVERSAL HEALTH CARE UNIVERSAL HEALTH CARE Unknown Import
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

Race: American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native HAwaiian or other Pacific Islander White Ethnicity: Non Hispanic or Latino Hispanic or Latino Language: English Spanish French Other Height: Feet: Inches: Weight:

PATIENT MEDICAL HISTORY
Injuries, Surgeries, Hospitalization
Pregnant Or Nursing: No Yes Unsure
Primary Care Physcian: Preferred Pharmacy City
How did you hear about our office? Last Eye Exam: NEVER 1 week 1 month 3 months 6 months 1 year 2 years 3 years or longer Doctor:
Prescription Medications: None
Drug Allergies: None
Over the Counter:

FAMILY MEDICAL HISTORY : Please note any family history (yourself, parents, grandparents, siblings, children; living or deceased) for the following conditions:

SET ALL TO NO

Disease/Condition	Yes	No	Relationship to You
Blindness
Crossed Eyes
Cataract
Glaucoma
Macular Degeneration or Retinal Detachment
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Thyroid Disease

HEALTH HISTORY : Do you currently, or have you ever had any problems in the following areas:

SET ALL TO NO

Eyes (Ocular symptoms)	Yes	No
Eye Pain or Soreness
Fatigue/Tired Eyes
Dryness/ Gritty Feeling
Redness
Burning
Itching
Excess Watering
Mucous Discharge
Eyes (Visual Symptoms)
Squinting
Glare
Light Sensitivity
Halos
Double Vision
Loss of Vision
Blurred Vision
Flashes
Floaters
Constitutional
Weight Loss/Gain
Fever
Skin
Rosacea
Eczema
Ears, Nose, Mouth, Throat
Allergies/Hay Fever
Sinus Congestion/Runny Nose
Respiratory
Asthma
Emphysema
Vascular/Cardivascular
Heart Problems/Disease
Vascular Disease
High Blood Pressure
High Cholesterol
Stroke
Gastrointestinal/Genitourinary
Irritable Bowel Syndrome/Corhn's disease
Genital/ Kidney/ Bladder
Endocrine
Thyroid/Other Glands
Diabetes
Lymphatic/Hematologic
Anemia
Bleeding Problems
Autoimmune
Rheumatoid Arthritis
Lupus
Neurological
Headaches
Migraines
Seizures
Alzheimer's
Parkinsons's
Psychiatric
Immune System

Eye History
Eye Injuries (Foreign Objects, Black eye, etc.)
Yes No
Eye Disease (Cataract, Glaucoma, Macular Degeneration, Pterygium, etc.)
Yes No
Eye Surgery (Cataract, Laser Vision Correction, etc.)
Yes No
If yes to any of the above, please explain what and when

Do you wear contact lenses? Yes No
If no, are you interested in trying contacts? Yes No
What contact lens solution do you use?


SOCIAL HISTORY
Smoking Status: Never Smoker Current every day smoker Current occasional smoker Former smoker Smoker, currernt status unknown Unknown if ever smoked Type: None Cigarettes Chewing Tobacco Cigar Pipe How Long:
Alcohol: No Yes Occasionally Socially Type: None Beer/Wine Hard Liquor How Long:
Illegal Drugs: No Yes Type: How Long:
Have you ever been exposed to or infected with sexually transmitted disease?

Are there any special needs of which we should be aware?
Autism Dementia Mentally challenged Hearing Loss Dyslexia/reading problems ADD/ADHD Other