New Patient Form

Demographics

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

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 Last 4 digits of 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 Dr. Keltgen, Kelsey Misc/Guardian

How did you hear about Seek?:

Billing Information

Is The Billing Address the Same?

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

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 Administrative Concepts, INC Aetna Allina Health Auxiant Avesis bind Blue Cross Blue Shield of MN BRMS CCStpa CHAMPVA Cigna Cigna Vision Continental Benefits Davis Vision Care Delta Vision Eyemed (First American Administrators Attn: OON Claims) Gallagher Bassett Services Inc HealthEZ HealthPartners Humana LaborCare Liberty HealthShare/Medcost Solutions Medi-Share Medica Medica Medicaid Medica2 Medicaid of Minnesota Medical Mutual of Ohio Medicare Meritain MetLife Multiplan National Vision Administrators Other/Not Listed Palmetto GBA Preferred One Prime West Health Plan SeeK VIP SelectCare Spectera (Out of Network) Superior Vision TriCare West Region UCare Minnesota UMR United HealthCare United HealthCare Vision (Out of Network) UnitedHealthcare Claim Division Vision Service Plan Wilson McShane
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:

Secondary

Insurance Information

Insurance Name:	None Administrative Concepts, INC Aetna Allina Health Auxiant Avesis bind Blue Cross Blue Shield of MN BRMS CCStpa CHAMPVA Cigna Cigna Vision Continental Benefits Davis Vision Care Delta Vision Eyemed (First American Administrators Attn: OON Claims) Gallagher Bassett Services Inc HealthEZ HealthPartners Humana LaborCare Liberty HealthShare/Medcost Solutions Medi-Share Medica Medica Medicaid Medica2 Medicaid of Minnesota Medical Mutual of Ohio Medicare Meritain MetLife Multiplan National Vision Administrators Other/Not Listed Palmetto GBA Preferred One Prime West Health Plan SeeK VIP SelectCare Spectera (Out of Network) Superior Vision TriCare West Region UCare Minnesota UMR United HealthCare United HealthCare Vision (Out of Network) UnitedHealthcare Claim Division Vision Service Plan Wilson McShane
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:

Tertiary

Insurance Information

Insurance Name:	None Administrative Concepts, INC Aetna Allina Health Auxiant Avesis bind Blue Cross Blue Shield of MN BRMS CCStpa CHAMPVA Cigna Cigna Vision Continental Benefits Davis Vision Care Delta Vision Eyemed (First American Administrators Attn: OON Claims) Gallagher Bassett Services Inc HealthEZ HealthPartners Humana LaborCare Liberty HealthShare/Medcost Solutions Medi-Share Medica Medica Medicaid Medica2 Medicaid of Minnesota Medical Mutual of Ohio Medicare Meritain MetLife Multiplan National Vision Administrators Other/Not Listed Palmetto GBA Preferred One Prime West Health Plan SeeK VIP SelectCare Spectera (Out of Network) Superior Vision TriCare West Region UCare Minnesota UMR United HealthCare United HealthCare Vision (Out of Network) UnitedHealthcare Claim Division Vision Service Plan Wilson McShane
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:

Comprehensive History

What Is Your Main Reason For Visit?

Either Check Boxes Or Write In Box Below

Routine Exam

Need Contact Lenses

Need Glasses

Medical Office Visit / Red Eye

History: - All No

Condition	Yes	No
Do You Wear Prescription Glasses?
Do you Wear OTC Readers / Cheaters?
Do You Wear Contact Lenses?
Do You Wear Sunglasses?
Do You Have Any Allergies To Medication?
Do You Have Seasonal Allergies?
Are You Pregnant?
Do You See Flashes Of Light In Your Eyes?
Do You See Floating Objects In Your Eyes?
Do You Have Temporary Blackouts Of Vision?
Do You Have Frequent Headaches?
Do You Have Lung Disease?
Do You Smoke?

Select Smoking Status From Drop Down:

Never a smoker Former Smoker (no longer smokes) Heavy Smoker (>10 Cigs/day) Light Smoker (<10 Cigs/day) Occasional Smoker (not daily) Unknown

Do You Drink Alcohol?

Last Medical Physical:
Last Eye Exam:

Please List Any And All Medications You Are Currently Taking, Including Prescription, Over The Counter, Supplements And Eye Drops:


List Allergies (Medications, Environmental, Etc)


Please Select Or List All Ocular Injuries, Surgeries Or Therapies You Have Had:

Family Doctor's Name:
Family Doctor's Clinic Name:

Have You Or A Family Member Been Diagnosed With:

Condition	Yes	No	Relationship: (Self, Mother, Father , Grandfather, Grandmother, Sibling)
Any Eye Disease
Cataracts
Glaucoma
Macular Degeneration
MS
Arthritis
Cancer
Diabetes
High Blood Pressure
Heart Disease
Autoimmune Disease
Thyroid Disease
High Cholesterol
Alzheimer's Disease Or Dementia

List Occupation And Hobbies

Check If You Participate In Activities Below:

Golf	Fishing	Snowboarding / Skiing	Boating
Bicycling	Over 4 Hours Of Computer Work	Gardening
Reading	Sewing	Shooting	Traveling

Policies, Consent / Submit Data

Please read the following policies

HIPAA Privacy

I understand that Seek Eye Care, PA may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit Dr. Keltgen & her associates to perform administrative duties, provide me with eye care services and products, process my vision benefit claims and communicate with me regarding vision care services provided by this location.

I can be assured that this location does not sell my personal health information of any kind to a third party for such party's own use. I acknowledge and agree that the location may submit my vision benefit claims to my plan sponsor or health plan to receive reimbursement directly for the vision services that I have received at this location.

Please notify one of our employees if you would like a copy of our "Notice of Privacy Practices."


Business Policies

• If you plan on using insurance benefits, insurance information must be presented before time of service. If you have not presented your insurance or have any questions about co-pays or fees please address the staff now.
• I understand that I am financially responsible for all charges left unpaid by insurance or vision plans. Payment made by the insurance carrier(s) and/or vision plan will be credited to the balance. The remaining balance will be billed to the patient/legal guardian.
• I understand that all co-pays, coinsurance and deductibles are due at the time of service.
• Fees for contact lens fittings which are not part of a routine eye exam are generally not covered by insurance and are due at the time of service.

Informed Consent for the Dilated Fundus Exam

The dilated eye exam allows the doctor to perform a more thorough eye health exam. Dilation is highly recommended for patients new to the practice, with an increase in floaters or flashes of light, who are highly nearsighted, with unexplained headaches or vision loss, who have experienced blunt head trauma or diagnosed with: diabetes, high blood pressure, high cholesterol, autoimmune disorders, cancer or retinal disease.

A dilated eye exam requires the use of eye drops that dilate your pupils. The drops require 15-25 minutes to take effect and cause sensitivity to light for 2-5 hours and blurry near vision for 1-3 hours. These side effects can make daily activities difficult, even with sunglasses. If necessary we can reschedule the dilation portion of the exam for a more convenient time.

There is No-Charge for this portion of the routine eye exam.

• Yes, I consent to having dilation done today.
• Yes, I consent to having dilation done today and will pay $20 for the Reversal drops.
OR

• I'd prefer to have a series of retinal photos. There may an additional charge of $39 for these photos.
OR

• No, I understand the importance of the dilated fundus exam and choose to skip this .

If you wish to schedule the dilation for another day please indicate the days you prefer here:

Please check, sign and date that you have read, understand, and agree to the above and click the submit data button to complete your online forms. Thank you!

Check:
Patient Signature:
Date: