New Patient Information Forms
What To Do
Hi, and welcome to Optimal Eye Care!
These pages have been designed to collect all the information necessary before Dr. Rhea can examine your eyes, evaluate your vision needs, or prescribe spectacles or contact lenses.
Please complete all the forms with all the appropriate information before you come in for your appointment.
When you finish, you
must
go to the "Save and Exit" tab and press the "Submit Data" button. If you don't press the Submit Data button before closing your browser window all the information you entered will be lost.
When you come in for your appointment, please be sure and bring your driver's license or other ID and your insurance card(s) as we will need to copy each of these for our records.
If you don't yet have an appointment, after pressing the "Submit Data" button, you can request an appointment at a time and date convenient for you by pressing the white "Request Appointment" button on the upper left of most Optimal Eye Care webpages.
Thanks for choosing Optimal Eye Care!
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
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Unknown
Single
Married
Separated
Divorced
Widowed
Child
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. Rhea, Chris
Misc/Guardian
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 Ins
Insurance Information
Insurance Name:
None
Aetna Health Insurance
BCBS
Block Vision
Blue Cross Blue Shield of Texas
Blue Cross/Blue Shield
Bravo Health
Cigna
Community Health Choice
Davis
Eye Med
First Health Network
GPA
Great West Health Care
Humana
Medicare
New Insurance
New Insurance
New Insurance
Opticare
PacifiCare
Preferred Health Network
Principle Financial Group
Principle Life Insurance Co.
Seafarers Health
Seafarers Health & Benefits
Spectera
Superior Vision
Texas Blue Cross Blue Shield
Texas Children's Health Plan
Texas Medicaid - National Heratige Insurance Company (NHIC)
Texas Medicare
Texas True Choice
TMHP - Traditional Medicaid
Tower Life Insurance Co.
Unicare
United Health Care
United Medical Resources
Vision Comp Plan
Vision Service Plan
VisionCare Plan/Compbenefits
Wellcare HMO, Inc.
Wells Fargo Thrid Party Admin
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 Ins
Insurance Information
Insurance Name:
None
Aetna Health Insurance
BCBS
Block Vision
Blue Cross Blue Shield of Texas
Blue Cross/Blue Shield
Bravo Health
Cigna
Community Health Choice
Davis
Eye Med
First Health Network
GPA
Great West Health Care
Humana
Medicare
New Insurance
New Insurance
New Insurance
Opticare
PacifiCare
Preferred Health Network
Principle Financial Group
Principle Life Insurance Co.
Seafarers Health
Seafarers Health & Benefits
Spectera
Superior Vision
Texas Blue Cross Blue Shield
Texas Children's Health Plan
Texas Medicaid - National Heratige Insurance Company (NHIC)
Texas Medicare
Texas True Choice
TMHP - Traditional Medicaid
Tower Life Insurance Co.
Unicare
United Health Care
United Medical Resources
Vision Comp Plan
Vision Service Plan
VisionCare Plan/Compbenefits
Wellcare HMO, Inc.
Wells Fargo Thrid Party Admin
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 Ins
Insurance Information
Insurance Name:
None
Aetna Health Insurance
BCBS
Block Vision
Blue Cross Blue Shield of Texas
Blue Cross/Blue Shield
Bravo Health
Cigna
Community Health Choice
Davis
Eye Med
First Health Network
GPA
Great West Health Care
Humana
Medicare
New Insurance
New Insurance
New Insurance
Opticare
PacifiCare
Preferred Health Network
Principle Financial Group
Principle Life Insurance Co.
Seafarers Health
Seafarers Health & Benefits
Spectera
Superior Vision
Texas Blue Cross Blue Shield
Texas Children's Health Plan
Texas Medicaid - National Heratige Insurance Company (NHIC)
Texas Medicare
Texas True Choice
TMHP - Traditional Medicaid
Tower Life Insurance Co.
Unicare
United Health Care
United Medical Resources
Vision Comp Plan
Vision Service Plan
VisionCare Plan/Compbenefits
Wellcare HMO, Inc.
Wells Fargo Thrid Party Admin
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:
Save and Exit
Please be sure to press the "Submit Data" button before closing your browser window or all your hard work will be lost!
After completing all forms please be sure to press "Submit Data" on the rightmost "Save and Exit" tab or all the information you entered will be lost.
Optimal Eye Care, P.C.,
2945 Gulf Freeway South Suite C,
League City, Texas 77573-6771 Phone 281.309.9700 Fax 281.309.9720
Content copyright
2011 - 2012
.
Optimal Eye Care, P.C
. All rights reserved.