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Insurance Information

Thank you for scheduling an exam at our office! We look forward to meeting you, but need a little more information about your upcoming visit before we are ready to see you. This form contains confidential information and is delivered to your doctor through a secure internet connection. Please fill it out as soon as possible. IF WE DO NOT RECEIVE THIS COMPLETED FORM BEFORE YOUR SCHEDULED APPOINTMENT TIME, WE MAY NEED TO RESCHEDULE YOUR APPOINTMENT TO ANOTHER DATE/TIME. If you have any questions, feel free to call us at 502-996-7450.

Patient Name

First name

Last name

What are we seeing you for :

Glasses Exam

Contact Exam

Diabetic Exam

Eye Infection

Eye Injury

Other

Will You Be Using Insurance

Yes

(please complete all applicable info below to avoid your appointment being delayed or rescheduled)

Vision Insurance :

Avesis

Davis

EyeMed

Passport

Spectera

Tricare

VSP

Other

Subscriber Name:

First Last

Date of Birth:

Last 4 SSN:

Member ID:

Primary Medical Insurance:

Aetna

Anthem

Humana

Medicare

United Health Care

Other

Subscriber Name:

First Last

Date of Birth:

Member ID:

Group ID:

Secondary Medical Insurance (if applicable):

Aetna

Anthem

Humana

Medicare

United Health Care

Other

Subscriber Name:

First Last

Date of Birth:

Member ID:

Group ID:

Demographics

Date

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Sex:

Birthdate:

Age:

Height :

ft and in

Weight :

lbs

Phone (Home):

Phone (Cell):

Employed:

Yes

Occupation:

Primary Physician:

City/Group:

Last Visit (Approx):

Previous Eye Doctor:

City/Group:

Last Visit (Approx):

Do You Wear Glasses :

All the time

Driving Only

Reading Only

Never

Do You Wear Contacts :

All the time

Occasionally

Never

Have You Ever Had:

Lazy Eye

Eye Injury

Eye Surgery

Eye Infection

Do You Routinely Experience or Currently Have :

Vision Loss

Blurry Vision

Double Vision

Dryness

Redness

Crusting/Discharge

Itchy Eyes

Burning Eyes

Watery Eyes

Light Sensitivity

Eye Pain

Stye/Sties

Floaters

Cataracts

Glaucoma

Macular Degeneration

Poor Color Vision

Medications You Are Currently Taking (List):

Allergies to Medications (List):

Other Allergies (List):

Do You Have :

Colitis

Chron’s Disease

Chronic Fatigue

Eczema/Psoriasis

Headaches

Seizures

Multiple Sclerosis

Diabetes

Thyroid Dysfunction

Asthma

Emphysema

Heart Disease

High Cholesterol

High Blood Pressure

Seasonal Allergies

Sinus Problems

Lupus

Arthritis

Blood Disorder

Fibromyalgia

Kidney Problems

Family History :

Cataracts

Yes

Unknown

Macular Degeneration

Yes

Unknown

Glaucoma

Yes

Unknown

Retinal Detachment

Yes

Unknown

Crossed/Lazy Eye

Yes

Unknown

Cancer

Yes

Unknown

Diabetes

Yes

Unknown

Heart Disease

Yes

Unknown

High Blood Pressure

Yes

Unknown

Arthritis

Yes

Unknown

Thyroid Disease

Yes

Unknown

Color Vision Problems

Yes

Unknown

Notice of Privacy Practices

Derby City Eye Care HIPAA Policy

I have been offered and/or received the notice of privacy practices for Derby City Eye Care.

Name

First Last

Date

MM slash DD slash YYYY

Digital Consent

By including my name below, I authorize Derby City Eye Care to communicate with me via mobile phone, text message, email, and any other kind of online or digital communication. I also authorize Derby City Eye Care to provide me with digital copies of my eyeglass prescription, contact lens prescription, and medical records upon my request. I understand that digital copies are not encrypted and agree to assume the risks associated with receiving them in this manner. I also understand that I may request paper copies of these materials at any time.

Name

First Last

Date

MM slash DD slash YYYY

Number