New Patient Questionnaire Insurance InformationThank 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. Please fill out this form as soon as possible. IF WE DO NOT RECEIVE THIS COMPLETED FORM BEFOREYOUR 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. What are we seeing you for : Glasses Exam Contact Exam Diabetic Exam Eye Infection Eye Injury Other Will you be using insurance (please bring all insurance cards with you to your appointment): Yes No (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):Subscriber Name: First Last Date of Birth: Member ID: Group ID:
