Demographics
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Miss
Address:
City:
State/ZipCode
TX
Home Phone:
Cell Phone:
SSN:
Email:
Birthdate:
Occupation:
Sex:
Male
Female
Employment Status:
Employed
Full-Time Student
Part-Time Student
Marital Status:
Single
Married
Separated
Divorced
Widowed
Employer/School Name:
Primary Doctor:
No Doctor Assigned
Dr. Nguyen, Antony
Dr. Tran, Cuong
Misc/Guardian
Preferred Language
(Declined)
English
Spanish
Race
(Declined)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Ethinicity
(Declined)
Hispanic or Latino
Not Hispanic or Latino
Height
ft
in
Weight
lbs
Billing Information
Is The Billing Address the Same?
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Miss
Address
City
State
ZipCode
TX
Home Phone:
Work Phone:
Vision Insurance
Insurance Information
Insurance Name:
None
Administrative Insurance Management
Adventist Risk Management, Inc.
Aetna US Healthcare
AH&L
Aim Administrators, Ltd
Always Vision
Ama Insurance Agency, Inc
Amcare Health
America's Choice Healthplan
American Maritime Officers Medical Plan
American Pioneer
Amerigroup
Anthem Blue Cross Blue Shield
Ashland Oil
Atlas Adminstrators
Avesis
Bankers Life & Casualty Co
Beech Street
Benefit Administration Services
Benefit Planners
BlockVision
Blue Bell Benefits Trust
Blue Choice Network
Blue Cross Blue Shield
Blue Cross Blue Shield Health Select
Blue Cross Blue Shield of Texas
Boon-Chapman
Bravo
Bravo Health
Care Improvement Plus - MEDICAL
CARE IMPROVEMENT PLUS - VISION
Carefirst Blue Cross Blue Shield
CelticCare
Central States SE & SW
Central United Life Insurance Company
Cigna Healthcare
Cigna Indemmenty Vision
Cna Health Partners
Coast to Coast
Cole Managed Vision
Community Health Choice
CompBenefit
Connecticut General Life Insurance Co
Continental General
Conventry Health Care
Coresource
Corporate Benefits Services of America
Cuna Mutual Life
DavisVision
Definity Health Insurance
E.B.A & M Corporation
Elder Health
Entrust
Erisa Adminstrative Services
Exxon Medicare Supplement
Eye Care for Kids
Eyemed Vision Care
First Health Network Benefit Plan
Freedom of Choice
Gallagher Benefit Administrators, Inc
GE Financial
GE Group Administrators
Geha
General Admission
GHI
GPA
Great West Healthcare
Group Administrators
Group Resource Inc
Guardian
Harrington Benefit Services, Inc
Hartford Insurance
HealthComp
Healthfirst Tpa
Healthscope Benefits
Healthsmart
HEALTHSPRING
HMO Blue Texas
Humana
Humana Care Choice Network
Insurance Systems
Jewish Family Services
John Alden Life Insurance Co
John Deere Health Care
Kaiser Permanente
Life Investors Ins Company of America
LifeRe Insurance Company
Medicaid (TMHP)
Medicare Part B
Memorial Hermann Hnp
MES Vision
Met Life Vision Care
Molina Healthcare
Mutual of Omaha
Mutual Protective/Medico Life
National Asbestos Workers Medical Fund
National Association of Letter Carriers
Navigator Health Insurance
New England Financial
New Era Life Insurance Companies
None
NVA/Heritage Optical
Old Surety Life Insurance Co
One Health Plan
Opticare
Pacific Life & Annuity Benefits Office
Pacificare
Performax
Physicians Life Insurance Co
Presidential Business Administrators
Principle Financial Group
Prinicple Life Insurance Co
Prudential Healthcare
REA Benefits
Select Care of Texas
Spectera - OPTUMHEALTH VISION
Stainless & Alloy
Standard Life & Accident Insurance Co
State Farm Health Insurance
Superior Vision
SUPERIOR VISION
Texas Children's Star
Texas Commission For The Blind
Texas Municipal League Group Benefits
Texas Rehabilitation Services
The Uhlmann Company
Thrivent Finacial For Lutherns
Tower Life Insurance Company
Tricare Southwest
TriSurant
Tryco Administrative Services
Ttx Company
Ullico/usa Life
Unicare
United American Insurance Company
United Commercial Travelers of America
United Food & Commercial Workers
United Health Care
United Healthcare-Texas Chip
United Medical Resources, Inc
Universal Fidelity Life Insurance
UPMC Health
Usaa Life Insurance Company
Veterans Universal Access
Vignette/benefit Planners
Vision Benefits of America
Vision Care Plan
Vision Med
Vision Service Plan
VisionCare
VSP
Wassau Benefits
Webtpa
Wellcare
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Not Primary
Primary on Account
Name:
Last, First MI
SSN:
Relationship to Insured:
Spouse
Child
Other
Sex:
Male
Female
Address:
City:
State:
Zip:
Phone Number:
Birthday:
Employer/School:
Medical Insurance
Insurance Information
Insurance Name:
None
Aetna
Blue Cross Blue Shield
Cigna
CoreSource
Great West Healthcare
Humana
Medicaid
New Era Employee Welfare Benefit Plan Trust
PHCS
Principal Financial Group
Star Mark
Tower Life Insurance Co.
Unicare
United Health Care
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:
Employer/School:
Medical Health Record
Who Is Your Primary Care Physician?:
What Is The Reason For Your Visit Today?:
Annual Eye Exam
Eye Illness
Follow up on physical
When Was Your Last Eye Exam?:
6 months
1 year
2 years
3+ years
What Are Your Hobbies?:
Please List Any Type Of Medications Your Are Currently Taking:
Do You Have Any Allergies?:
Patient Medical History:
Good health
Arthritis
Asthma
Diabetes Type 2
Diabetes Type 1
HTN
Headaches
Heart Condition
Hx of Drug/Alcohol Abuse
Hypothyroidism
Inflammatory Bowel Disease
Smoking
Seizure Disorder
Thyroid Disease
Pregnancy
Nursing
Diagnosed As HIV+
Obesity
Family Medical History:
None
Unsure
Adopted
Diabetes
HTN
Cancer
Cardiovascular Disease
Kidney Disease
Lupus
COPD
Thyroid
Arthritis
High Blood Pressure
Do You Have Headaches Issues?:
No
Yes
Occasional
Constant
Notes For The Doctors:
Are You Pregnant or Nursing?:
NO / NA
Yes
Unsure
Are You Currently Taking Any Vitamins?:
None
Multi-vitamin
A
C
Calcium
E
Fish Oil
Lutein
Xanten
Zinc
Are You Taking Any Over the Counter Drugs?:
None
Aspirin
Ibuprofen
Acetomenophin
Did You Have Any Injuries, Surgeries, Hospitalizations?:
What Are Your Occupational/Vocational Vision Needs?: