New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Mstr. 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
Primary Doctor	No Doctor Assigned Jerrad Mills, O.D. Jerrad Mills, O.D.	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Insurance Information

Insurance Name:	None AARP AARP Medicare Advantage (HMO) UnitedHealthcare AARP Unitedhealthcare Medicare advantage Aetna Aetna Choice POS II Aetna Medicare Advantage Air Products Baytown Air Products Distribution Air Products Operations Air Products Pasadena Akzo Alcon All Savers Amerigroup Ameritas Anthem Blue Cross Blue Shield ASR Health Benefits Assurant Health Access BASF Bayport Polymer Baystar Polymers Blue Cross Blue Shield Blue Cross Blue Shield Medicare Blue Cross Blue Shield of Alabama Blue Cross Blue Shield of Georgia Blue Cross Blue Shield of Illinois Blue Cross Blue Shield of Kansas City Blue Cross Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue Shield of Michigan Blue Cross Blue Shield of Minnesota Blue Cross Blue Shield of New Jersey Blue Cross Blue Shield of Oklahoma Blue Cross Blue Shield of Tennessee Blue Cross Blue Shield of Tennessee Blue Cross Blue Shield of Texas Blue Cross Medicare Advantage of Texas Boilermaker National Health & Welfare Braskem Care Improvement Plus ChampVA Cigna Cigna Medicare Supplement CignaVision Combined Insurance Co Community Healthcare Choice, Inc Coventry Health Care Of Georgia Dars Davis Vision Entrust Eye Center of Texas Eyemed Eyemed (National Elevator) - Not Covered Eyemed Aetna Eyemed Discount Plan First Health Fox Everett GEHA Group and Pension Administration Guardian Hartford Health Choice Health Smart Benefits Highmark West Virginia Horace Mann Houston Ammonia Terminal Humana Humana Medicare Advantage JX Nippon Chemical Texas, Inc. Kelsey Care Advantage - HMO M Health Select Maritime Association - I.L.A. Medicare Medicare Complete / Unitedhealthcare Medicare Railroad Retirement Medicare Supplement Memorial Health Memorial Herman Meritain Health Metlife Metlife VSP Discount Molina Healthcare Molina Marketplace Mutual of Omaha MVP Select Care NALC Health Benefit Plan National Asbestos Workers New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance Omaha Insurance Co optisource Other Oxyvinyls Pacific Source Physicians Mutual Plumbers Local 68 Plumbers Local Union 68 Group Protection Plan Principal Life Insurance Protec Safety Renaissance Physician Organization Secure Horizons Shenandoah Life Insurance Co State Farm Stolt Nielson Stolt Nielson Transportation Stolt Terminals Superior Vision Texans Plus HMO Texas Health Springs TML IEBP Total Petrochemicals Total Petrochemicals FB Total Petrochemicals FO Trans American Tricare UMR United American UnitedHealthcare UnitedHealthcare Group Medicare Advantage (PPO) UnitedHealthcare Vision UnitedHealthcareComplete Vision Care Plan VSP VSP Access Indemnity Plan VSP Choice Exam Plus VSP Choice Plan VSP Discount VSP Exam Only Plan VSP Exam Plus Plan VSP Exam Plus With Allowances Plan VSP Primary Eye Care VSP Protec Safety VSP Signature Plan VSP Vision Savings Pass Wellcare Zeon
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 AARP AARP Medicare Advantage (HMO) UnitedHealthcare AARP Unitedhealthcare Medicare advantage Aetna Aetna Choice POS II Aetna Medicare Advantage Air Products Baytown Air Products Distribution Air Products Operations Air Products Pasadena Akzo Alcon All Savers Amerigroup Ameritas Anthem Blue Cross Blue Shield ASR Health Benefits Assurant Health Access BASF Bayport Polymer Baystar Polymers Blue Cross Blue Shield Blue Cross Blue Shield Medicare Blue Cross Blue Shield of Alabama Blue Cross Blue Shield of Georgia Blue Cross Blue Shield of Illinois Blue Cross Blue Shield of Kansas City Blue Cross Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue Shield of Michigan Blue Cross Blue Shield of Minnesota Blue Cross Blue Shield of New Jersey Blue Cross Blue Shield of Oklahoma Blue Cross Blue Shield of Tennessee Blue Cross Blue Shield of Tennessee Blue Cross Blue Shield of Texas Blue Cross Medicare Advantage of Texas Boilermaker National Health & Welfare Braskem Care Improvement Plus ChampVA Cigna Cigna Medicare Supplement CignaVision Combined Insurance Co Community Healthcare Choice, Inc Coventry Health Care Of Georgia Dars Davis Vision Entrust Eye Center of Texas Eyemed Eyemed (National Elevator) - Not Covered Eyemed Aetna Eyemed Discount Plan First Health Fox Everett GEHA Group and Pension Administration Guardian Hartford Health Choice Health Smart Benefits Highmark West Virginia Horace Mann Houston Ammonia Terminal Humana Humana Medicare Advantage JX Nippon Chemical Texas, Inc. Kelsey Care Advantage - HMO M Health Select Maritime Association - I.L.A. Medicare Medicare Complete / Unitedhealthcare Medicare Railroad Retirement Medicare Supplement Memorial Health Memorial Herman Meritain Health Metlife Metlife VSP Discount Molina Healthcare Molina Marketplace Mutual of Omaha MVP Select Care NALC Health Benefit Plan National Asbestos Workers New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance Omaha Insurance Co optisource Other Oxyvinyls Pacific Source Physicians Mutual Plumbers Local 68 Plumbers Local Union 68 Group Protection Plan Principal Life Insurance Protec Safety Renaissance Physician Organization Secure Horizons Shenandoah Life Insurance Co State Farm Stolt Nielson Stolt Nielson Transportation Stolt Terminals Superior Vision Texans Plus HMO Texas Health Springs TML IEBP Total Petrochemicals Total Petrochemicals FB Total Petrochemicals FO Trans American Tricare UMR United American UnitedHealthcare UnitedHealthcare Group Medicare Advantage (PPO) UnitedHealthcare Vision UnitedHealthcareComplete Vision Care Plan VSP VSP Access Indemnity Plan VSP Choice Exam Plus VSP Choice Plan VSP Discount VSP Exam Only Plan VSP Exam Plus Plan VSP Exam Plus With Allowances Plan VSP Primary Eye Care VSP Protec Safety VSP Signature Plan VSP Vision Savings Pass Wellcare Zeon
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 Information

Insurance Name:	None AARP AARP Medicare Advantage (HMO) UnitedHealthcare AARP Unitedhealthcare Medicare advantage Aetna Aetna Choice POS II Aetna Medicare Advantage Air Products Baytown Air Products Distribution Air Products Operations Air Products Pasadena Akzo Alcon All Savers Amerigroup Ameritas Anthem Blue Cross Blue Shield ASR Health Benefits Assurant Health Access BASF Bayport Polymer Baystar Polymers Blue Cross Blue Shield Blue Cross Blue Shield Medicare Blue Cross Blue Shield of Alabama Blue Cross Blue Shield of Georgia Blue Cross Blue Shield of Illinois Blue Cross Blue Shield of Kansas City Blue Cross Blue Shield of Louisiana Blue Cross Blue Shield of Massachusetts Blue Cross Blue Shield of Michigan Blue Cross Blue Shield of Minnesota Blue Cross Blue Shield of New Jersey Blue Cross Blue Shield of Oklahoma Blue Cross Blue Shield of Tennessee Blue Cross Blue Shield of Tennessee Blue Cross Blue Shield of Texas Blue Cross Medicare Advantage of Texas Boilermaker National Health & Welfare Braskem Care Improvement Plus ChampVA Cigna Cigna Medicare Supplement CignaVision Combined Insurance Co Community Healthcare Choice, Inc Coventry Health Care Of Georgia Dars Davis Vision Entrust Eye Center of Texas Eyemed Eyemed (National Elevator) - Not Covered Eyemed Aetna Eyemed Discount Plan First Health Fox Everett GEHA Group and Pension Administration Guardian Hartford Health Choice Health Smart Benefits Highmark West Virginia Horace Mann Houston Ammonia Terminal Humana Humana Medicare Advantage JX Nippon Chemical Texas, Inc. Kelsey Care Advantage - HMO M Health Select Maritime Association - I.L.A. Medicare Medicare Complete / Unitedhealthcare Medicare Railroad Retirement Medicare Supplement Memorial Health Memorial Herman Meritain Health Metlife Metlife VSP Discount Molina Healthcare Molina Marketplace Mutual of Omaha MVP Select Care NALC Health Benefit Plan National Asbestos Workers New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance New Insurance Omaha Insurance Co optisource Other Oxyvinyls Pacific Source Physicians Mutual Plumbers Local 68 Plumbers Local Union 68 Group Protection Plan Principal Life Insurance Protec Safety Renaissance Physician Organization Secure Horizons Shenandoah Life Insurance Co State Farm Stolt Nielson Stolt Nielson Transportation Stolt Terminals Superior Vision Texans Plus HMO Texas Health Springs TML IEBP Total Petrochemicals Total Petrochemicals FB Total Petrochemicals FO Trans American Tricare UMR United American UnitedHealthcare UnitedHealthcare Group Medicare Advantage (PPO) UnitedHealthcare Vision UnitedHealthcareComplete Vision Care Plan VSP VSP Access Indemnity Plan VSP Choice Exam Plus VSP Choice Plan VSP Discount VSP Exam Only Plan VSP Exam Plus Plan VSP Exam Plus With Allowances Plan VSP Primary Eye Care VSP Protec Safety VSP Signature Plan VSP Vision Savings Pass Wellcare Zeon
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

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