Select Office Centennial Commons Oak Court Wolfcreek Patient Status New Patient Current Patient Not a Patient PATIENT INFORMATION Birth Month January February March April May June July August September October November December Birth Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year Age State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  Tel-( ) - Alt Tel-( ) - SS#- - Gender Male Female Marital Status Single Married Divorced Widowed   Phone-( ) -  Whom may we thank for referring you to us?      PATIENT EMPLOYMENT INFORMATION     Work Phone-() -  State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   If the RESPONSIBLE PERSON and PATIENT Info is the same, check here Relationship to Patient Self Spouse Parent Dependant Other Patient Status New Patient Current Patient Not a Patient  FINANCIAL RESPONSIBILITY INFORMATION   Birth Month January February March April May June July August September October November December Birth Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year Age State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  Phone-( ) -  SS # - -  Gender Male Female Marital Status Single Married Divorced Widowed State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  RESPONSIBLE PERSON EMPLOYMENT INFORMATION    Work Phone-( ) -  State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  Pre-Approval Do we accept your insurance? Most Likely ...but we still have to process it. Depending on your insurance provider, this process can be time consuming while we try to get the approval necessary for us to proceed with your eyecare plan. Sometimes we find out that your insurance company may have a problem with your coverage that we can correct for you, before you even enter our office! By completing this form on-line, we can take the guess work out of the claim process for you and do all the processing work. We truly want to make your visit to our office a pleasant visit, so our experienced staff will go to work on getting the best coverage possible that you are entitled to by your insurance carrier. Many times we find situations where your medical insurance and your vision insurance can be applied in conjunction with each other to better cover your needs, so if you have medical insurance please enter your medical insurance carrier information below. If the Patient has Medical Insurance, please check here   If the Patient has Secondary Medical Insurance, please check here  If the Patient has Vision Insurance, please check here  If the PRIMARY & RESPONSIBLE PERSON Insurance Info is the same, check here Relationship to Patient Self Spouse Parent Dependant Other Patient Status New Patient Current Patient Not a Patient PRIMARY Insurance Person & Info Birth Month January February March April May June July August September October November December Birth Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year Age State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  Phone-( ) -  SS # - -  Gender Male Female PRIMARY Insurance Company Insurance Phone-( ) - If the SECONDARY& RESPONSIBLE PERSON Insurance Info is the same, check here Relationship to Patient Self Spouse Parent Dependant Other Patient Status New Patient Current Patient Not a Patient SECONDARY Insurance Person & Info Birth Month January February March April May June July August September October November December Birth Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year Age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 ? State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  Phone-( ) -  SS # - -  Gender Male Female SECONDARY Insurance Company   Insurance Phone-( ) -   If the VISION & RESPONSIBLE PERSON Insurance Info is the same, check here Relationship to Patient Self Spouse Parent Dependant Other Patient Status New Patient Current Patient Not a Patient VISION Insurance Person & Info Birth Month January February March April May June July August September October November December Birth Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Birth Year Age 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 ? State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  Phone-( ) -  SS # - -  Gender Male Female VISION Insurance Company   Insurance Phone-( ) - OTHER INFORMATION - You may elaborate on any information below, and/or in the office notes: I read/agree to the Policy: