Stone Oak Gastroenterology Patient Portal
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MI
Primary Insurance Company
----Select-----
AARP/UHC/SEC HRZN/WELLMED
ADMINISTRATIVE CONCEPTS INC
ADVANTAGE SUPERIOR HEALTHPLAN
AETNA
ALL SAVERS/UHC
ALLIED
ALLIED BENEFIT SYSTEMS INC
ALLIED NATIONAL
AMBETTER/SUPERIOR (ACA)
AMERIGROUP MCR/MCD HMO
AMERIGROUP WELLMED
APWU
ASAR HEALTH BENEFITS/CIGNA
BCBS HEALTH SELECT
BCBS MEDICARE ADVTG HMO
BCBS MEDICARE ADVTG PPO
BCBS OF TEXAS
BCBS TEXAS FEDERAL
BOON CHAPMAN BENEFIT ADM INC
BUPA
CAPROCK HEALTHPLANS
CAPROCK/UHSS
CARE IMPROVEMENT PLUS
CARE IMPROVEMENT PLUS/UHC
CHAMPVA
CHRISTIAN BROS
CHRISTIAN CARE/ MEDI SHARE
CIGNA
CIGNA BENEFITS
CIGNA GREAT WEST
CIGNA HEALTH CARE
CIGNA HEALTH/APWU
CIGNA HEALTHCARE/NALC
CIGNA/CAPROCK
CIGNA/CHRISTIAN BROTHERS SERVICES
CIGNA/CORESOURCE
CIGNA/GILSBAR
CIGNA/HEALTHGRAM
CIGNA/HEALTHPLAN
CIGNA/HEALTHSPRINGS/BRAVOHEALTH/WELLMED
CIGNA/HLTH SPRGS/WELLMED
CIGNA/PBA
COEUR
COMMUNITY FIRST HEALTH
COMMUNITY FIRST HEALTH HMO
CONSOLIDATED ADMIN. HEALTH PLAN
CORESOURCE
CORESOURCE/AETNA
COVENTRY HCC
DIRECT CARE ADMINISTRATION
DRISCOLL HEALTH PLAN
EBPA COMMERCIAL
EBSO INC
FOCUS HEALTH SOLUTIONS LLC
FOREIGN SERVICE BENEFIT PLAN
FREEDOM LIFE INS
FREEDOM LIFE/CIGNA
GEHA/ UNITED HEALTH INTERGRATED
GEHA/FEHB MEDICAL
GEHA/UHC
GEHA/UHC CHOICE PLUS
GILSBAR, LLC
GILSBAR/CIGNA
GILSBAR/UICW
GMMINC/AETNA
GOLDEN RULE INSURANCE COMPANY
GPA
GROUP PENSION ADM
GROUP PENSION ADMIN (GPA)
HEALTH PARTNERS
HEALTH SMART/CYPRESS BENEFIT ADMINISTRATORS
HEALTH SPRING LIFE AND HEALTH
HEALTH TX MEDICAL GROUP
HEALTHFIRST OF NEW YORK
HEALTHSMART BENEFIT SOLUTIONS
HEALTHSMART PREFERRED
HUMANA (COMMERCIAL)
HUMANA GOLD MCR ( PPO)
HUMANA GOLD MEDICARE HMO
HUMANA MCR ADV PPO TRS
HUMANA MCR ADVTG PPO
HUMANA MCR HEALTHSELECT
HUMANA X (EXCHANGE PLAN)
IMAGINE HEALTH/AMERIBENIEC GROUP
INTERNATIONAL BENEFITS ADMIN/ADVANTHEALTH
LIBERTY HEALTH SHARE/MEDCOST SOLUTIONS
LIFE SHIELD NATIONAL CARRIER/PHCS/INTERNATIONAL BENEFITS ADM
LIFESTYLE HEALTH PLANS(FIRST HEALTH)
LUCENT HEALTH
MASTRO HEALTH
MAYO HEALTH SOLUTIONS/FIRST HEALTH
MEDI SHARE
MEDICAID AMERIGROUP STAR
MEDICAID COMMUNITY FIRST
MEDICAID MOLINA STAR PLUS
MEDICAID SUPERIOR
MEDICAL MUTUAL
MEDICARE PART B
MEDICARE RR
MEDSHARE/PHCS
MEMORIAL HERMAN HEALTH SOLUTIONS/PHCS
MERITAIN
MHBP/AETNA
MOLINA HEALTHCARE
MOLINA HEALTHCARE OF TEXAS MMP
MOLINA MEDICARE DUAL MMP
MULTIPLAN
MUTUAL OF OMAHA INS
MUTUAL OF OMAHA MCR ADVANTAGE
MVP HEALTHCARE
OSCAR HEALTH PLANS
OXFORD HEALTH PLAN/UHC
PACIFIC SOURCE
PHCS HEALTHCARE
PHCS/BAKERS BENEFITS ADMINISTRATORS
PHCS/PROVIDENCE
PHILADELPHIA AMER LIFE
PREFERRED ONE ADMINISTATOR
PRIVATE PAY
PROFESSIONAL BENEFIT ADM INC
PROFESSIONAL BENEFIT ADMIN/CIGNA
PROSPECT HEALTH NETWORK INC
SAMBA
SAMBA HEALTH BENEFIT PLAN
SAN ANTONIO VA FEE
SECURE HORIZONS/WELLMED
SHEET METAL WORKERS/UHIS
Sonobella/Body Sculpt LLC
STUDENT RESOURCES
SUPERIOR HEALTH PLAN STAR PLUS
SYMETRA SELECT BENEFIT
TEXAS MEDICAID (TMHP)
THE KEMPTON COMPANY
THE PRUDENTIAL
TML GROUP BENEFITS
TRICARE FOR LIFE
TRICARE PRIME
TRICARE STANDARD
TRIWEST WPS VAPC3
UHC MEDICAID TX STAR
UHC/CARE IMPROVEMENT PLUS
UHC/GEHA SHARED SERVICES
UHC/MCR DIRECT
UMR
UMR/UHC
UMR/UHC/WTC
UNITED AMERICAN INSURANCE
UNITED HEALTH CARE
UNITED HEALTH CARE (RAILROAD)
UNITED HEALTH CARE NEXUS ACO
UNITED HEALTH CARE/MCR COMPLETE
UNITED HEALTHCARE MEDICARE PPO
UNITED HEALTHCARE NAVIGATE
UNITED HEALTHCARE WEST
VETERAN ADMINISTRATION
WEBTPA
WELLCARE
WELLFLEET/CIGNA
WELLMED
WELLMED FOCUS MCR HMO
WELLMED SECURE HORIZONS
WORLD TRADE CENTER HP/UMR
6098
6041
1210
475
2060
6111
1587
475
2003
6065
6062
1076
6060
6016
6125
6040
6053
6045
1448
475
6080
6004
475
475
1708
5666
6135
45
475
6236
6068
6175
2115
6040
2071
6173
475
475
6172
45
6019
5739
6225
45
5778
5742
475
6007
1435
5900
6230
475
475
6137
475
6029
475
6165
1774
6223
475
6106
2003
5871
1924
475
1884
950
475
1021
6018
2030
2060
1588
6231
5969
6035
475
1086
1145
475
475
475
5941
6082
6163
TRICARE EAST REGION
SELF PAY
6048
475
6162
6191
Tricare West
Medicare - Texas
Ambetter
UMR (formerly UMR Wausau)
VAPCCC Region 3
Medicare - Pennsylvania
Blue Cross Blue Shield of Texas
Web TPA / Community Health Electronic claims / CHEC
Sheet Metal Worker's National Health Fund SMW
Tricare
UHCP / UHC Dual Complete - Oxford Medicare Network
FIRST HEALTH - THE LEWER AGENCY
UNITED HEALTHCARE
Oscar Health
TRIWEST HEALTHCARE ALLIANCE PC3(VAPCCC REGIONS 1-6)
Tricare for Life HCFA
BCBS-Federal
UnitedHealthcare
Humana
Bankers Life
TRIWEST WPS MVH VAPC3
UnitedHealthcare West Encounters - Texas
Medicaid - Texas
Commonwealth Administrators, LLC
CIGNA HealthCare
Medicare Railroad
WellMed Healthcare
Health Texas Medical Group
705
2059
Mutual of Omaha
GEHA
Benefit Management Services
AARP MedicareComplete insured through UnitedHealthcare
State Farm Insurance Company
UnitedHealthcare / All Savers Insurance
6026
5666
Wellmed Medical
5741
6232
Gilsbar
Blue Cross Blue Shield of South Carolina(State Health Plan)
Blue Cross Blue Shield of Illinois
Care Improvement Plus (CIP)
USAA
MultiPlan GEHA
United States Automobile Association (USAA)
Humana MCD
CapRock Health Plan - Verity
Kempton Group Administrators
Texas Medicaid & Healthcare Partnership (TMHP)
6170
6087
1003
6119
6031
5989
6158
Medicare - Railroad
Continental General Insurance Company
MediShare (Christian Care Ministries)
AETNA MEDICARE
6050
Community First
WESTERN UNITED LIFE
Veterans Administration Patient Centered CCP Region 3
CHAMPVA - HAC
OXFORD MEDICARE NETWORK - AARP MEDICARECOMPLETE
CIGNA - PPO
Hartford
6147
New Era Employee Welfare Benefit
Colonial Penn Life Insurance
Health Cost Solutions
6117
PHCS GEHA
Humana Gold Plus
Capitol Administrators
Wellcare of Texas
Unicare
National Association of Letter Carriers (NALC)
Superior Health Plan (Ambetter) - Medical
Physicians Mutual Insurance Company
1168
5950
6097
Amerigroup Community Care
Group and Pension Administrators
Transamerica Life Insurance Company
1086
6097
Philadelphia American Life Insurance Company
American National Insurance Company (ANICO)
Humana Gold Choice
5677
Advantage Health Solutions
Molina Healthcare of Texas
CLOVER HEALTH (FORMERLY CAREPOINT HEALTH PLAN)
AARP Medicare Supplement Plans insured by UHIC
PIPA
Allied Benefit Systems, Inc.
1834
UnitedHealthcare / UHIS - UnitedHealth Integrated Services
Medicaid - Washington
..................................................
6072
Amerigroup Corporation
TRIWEST HEALTHCARE ALLIANCE PC3
FRIDAY HEALTH PLANS
Maxor Administrative Services
90 DEFREE BENEFITS
UnitedHealthcare / UnitedHealthcare West
AFSA
MOAA MEDIPLUS
BSBC
UnitedHealthOne / UnitedHealthcare Life Insurance Company
Hartford Life Insurance Company
FRIDAY HEALTHPLANS
FRIDAY HEALTH PLAN
Sierra Health and Life (Claims)
Assurant Health Self-Funded (Allied Benefit)
Trustmark Insurance Company
Government Employees Hospital Association (GEHA)
vumi
UOLIC
Loyal American Life (Medicare Supplement)
Blue Cross Medicare Advantage PPO/HMO
UnitedHealthcare Medicare Solutions / Medicare Advantage
PAPER
AMERIGROUP
FRIDAY
UnitedHealthcare / All Savers Alternate Funding
HealthSmart Preferred Care
USAA LIFE
IMAGINE HEALTH
SBMA
WPS Health Insurance
N/A
Self Insured Services Company (SISCO)
Meritain Health
UPMC Health Plan
SUPERIOR INSURANCE SERVICES
UnitedHealthOne / Golden Rule
Indian Health Services/Veteran Affairs
TREST MARK
Optum / Salt Lake County (Medicaid)
INSURANCE BENEFITS SYSTEMS
TRANSAMERICA LIFE INSURANCE COMPANY (TLIC)
EMR
10000
United American Insurance Company
FMH Benefit Services, Inc.
International Benefit Administrator
PLANSTIN ADM PHCS
UNITED WORLD LIFE INS CO
Liberty Health Advantage
Tall Tree Administrators
LHS/MedCost Solutions LLC
CHAMPVA Claims
Fringe Benefit Management
TN
BCBS
Centene Corp
State Farm Insurance
MANHATTAN LIFE INSURANCE COMPANY
UNITEDHEALTHCARE MEDICARE SOLUTIONS / UNITEDHEALTHCARE MEDICARECOMPLETE (FORMERLY SECUREHORIZONS)
DIRECT CARE ADMINISTRATORS
SELMAN AND COMPANY
Umited health care
Blue Cross Blue Shield of Nebraska
UnitedHealthcare Medicare Solutions / MedicareComplete
AMA Insurance Agency
EMI Health
Last Name
*
Insurance Plan/Name
Gender
*
Male
Female
Insurance ID#
DOB
*
(mm-dd-yyyy)
Group ID#
Age
Insured Name
SSN
(###-##-####)
Insured DOB (mm-dd-yyyy)
Race
American Indian
Alaska Native
Native American
Asian
Black
Native Hawaiian
Other Pacific Islander
White
Patient declined to provide
African American
Unknown
Other
Insured Relationship
Self
Spouse
Father
Mother
Other
Marital Status
Single
Married
Separated
Divorced
Widow
Other
Address
Work Status
Employed Full Time
Part Time
Student
Disabled
Unemployed
Retired
City
State
------Select-------
AL
AK
AZ
AR
CA
CO
CT
DE
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
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Contact Information
Secondary Insurance Information
Address1
Secondary Insurance Company
----Select-----
AARP/UHC/SEC HRZN/WELLMED
ADMINISTRATIVE CONCEPTS INC
ADVANTAGE SUPERIOR HEALTHPLAN
AETNA
ALL SAVERS/UHC
ALLIED
ALLIED BENEFIT SYSTEMS INC
ALLIED NATIONAL
AMBETTER/SUPERIOR (ACA)
AMERIGROUP MCR/MCD HMO
AMERIGROUP WELLMED
APWU
ASAR HEALTH BENEFITS/CIGNA
BCBS HEALTH SELECT
BCBS MEDICARE ADVTG HMO
BCBS MEDICARE ADVTG PPO
BCBS OF TEXAS
BCBS TEXAS FEDERAL
BOON CHAPMAN BENEFIT ADM INC
BUPA
CAPROCK HEALTHPLANS
CAPROCK/UHSS
CARE IMPROVEMENT PLUS
CARE IMPROVEMENT PLUS/UHC
CHAMPVA
CHRISTIAN BROS
CHRISTIAN CARE/ MEDI SHARE
CIGNA
CIGNA BENEFITS
CIGNA GREAT WEST
CIGNA HEALTH CARE
CIGNA HEALTH/APWU
CIGNA HEALTHCARE/NALC
CIGNA/CAPROCK
CIGNA/CHRISTIAN BROTHERS SERVICES
CIGNA/CORESOURCE
CIGNA/GILSBAR
CIGNA/HEALTHGRAM
CIGNA/HEALTHPLAN
CIGNA/HEALTHSPRINGS/BRAVOHEALTH/WELLMED
CIGNA/HLTH SPRGS/WELLMED
CIGNA/PBA
COEUR
COMMUNITY FIRST HEALTH
COMMUNITY FIRST HEALTH HMO
CONSOLIDATED ADMIN. HEALTH PLAN
CORESOURCE
CORESOURCE/AETNA
COVENTRY HCC
DIRECT CARE ADMINISTRATION
DRISCOLL HEALTH PLAN
EBPA COMMERCIAL
EBSO INC
FOCUS HEALTH SOLUTIONS LLC
FOREIGN SERVICE BENEFIT PLAN
FREEDOM LIFE INS
FREEDOM LIFE/CIGNA
GEHA/ UNITED HEALTH INTERGRATED
GEHA/FEHB MEDICAL
GEHA/UHC
GEHA/UHC CHOICE PLUS
GILSBAR, LLC
GILSBAR/CIGNA
GILSBAR/UICW
GMMINC/AETNA
GOLDEN RULE INSURANCE COMPANY
GPA
GROUP PENSION ADM
GROUP PENSION ADMIN (GPA)
HEALTH PARTNERS
HEALTH SMART/CYPRESS BENEFIT ADMINISTRATORS
HEALTH SPRING LIFE AND HEALTH
HEALTH TX MEDICAL GROUP
HEALTHFIRST OF NEW YORK
HEALTHSMART BENEFIT SOLUTIONS
HEALTHSMART PREFERRED
HUMANA (COMMERCIAL)
HUMANA GOLD MCR ( PPO)
HUMANA GOLD MEDICARE HMO
HUMANA MCR ADV PPO TRS
HUMANA MCR ADVTG PPO
HUMANA MCR HEALTHSELECT
HUMANA X (EXCHANGE PLAN)
IMAGINE HEALTH/AMERIBENIEC GROUP
INTERNATIONAL BENEFITS ADMIN/ADVANTHEALTH
LIBERTY HEALTH SHARE/MEDCOST SOLUTIONS
LIFE SHIELD NATIONAL CARRIER/PHCS/INTERNATIONAL BENEFITS ADM
LIFESTYLE HEALTH PLANS(FIRST HEALTH)
LUCENT HEALTH
MASTRO HEALTH
MAYO HEALTH SOLUTIONS/FIRST HEALTH
MEDI SHARE
MEDICAID AMERIGROUP STAR
MEDICAID COMMUNITY FIRST
MEDICAID MOLINA STAR PLUS
MEDICAID SUPERIOR
MEDICAL MUTUAL
MEDICARE PART B
MEDICARE RR
MEDSHARE/PHCS
MEMORIAL HERMAN HEALTH SOLUTIONS/PHCS
MERITAIN
MHBP/AETNA
MOLINA HEALTHCARE
MOLINA HEALTHCARE OF TEXAS MMP
MOLINA MEDICARE DUAL MMP
MULTIPLAN
MUTUAL OF OMAHA INS
MUTUAL OF OMAHA MCR ADVANTAGE
MVP HEALTHCARE
OSCAR HEALTH PLANS
OXFORD HEALTH PLAN/UHC
PACIFIC SOURCE
PHCS HEALTHCARE
PHCS/BAKERS BENEFITS ADMINISTRATORS
PHCS/PROVIDENCE
PHILADELPHIA AMER LIFE
PREFERRED ONE ADMINISTATOR
PRIVATE PAY
PROFESSIONAL BENEFIT ADM INC
PROFESSIONAL BENEFIT ADMIN/CIGNA
PROSPECT HEALTH NETWORK INC
SAMBA
SAMBA HEALTH BENEFIT PLAN
SAN ANTONIO VA FEE
SECURE HORIZONS/WELLMED
SHEET METAL WORKERS/UHIS
Sonobella/Body Sculpt LLC
STUDENT RESOURCES
SUPERIOR HEALTH PLAN STAR PLUS
SYMETRA SELECT BENEFIT
TEXAS MEDICAID (TMHP)
THE KEMPTON COMPANY
THE PRUDENTIAL
TML GROUP BENEFITS
TRICARE FOR LIFE
TRICARE PRIME
TRICARE STANDARD
TRIWEST WPS VAPC3
UHC MEDICAID TX STAR
UHC/CARE IMPROVEMENT PLUS
UHC/GEHA SHARED SERVICES
UHC/MCR DIRECT
UMR
UMR/UHC
UMR/UHC/WTC
UNITED AMERICAN INSURANCE
UNITED HEALTH CARE
UNITED HEALTH CARE (RAILROAD)
UNITED HEALTH CARE NEXUS ACO
UNITED HEALTH CARE/MCR COMPLETE
UNITED HEALTHCARE MEDICARE PPO
UNITED HEALTHCARE NAVIGATE
UNITED HEALTHCARE WEST
VETERAN ADMINISTRATION
WEBTPA
WELLCARE
WELLFLEET/CIGNA
WELLMED
WELLMED FOCUS MCR HMO
WELLMED SECURE HORIZONS
WORLD TRADE CENTER HP/UMR
6098
6041
1210
475
2060
6111
1587
475
2003
6065
6062
1076
6060
6016
6125
6040
6053
6045
1448
475
6080
6004
475
475
1708
5666
6135
45
475
6236
6068
6175
2115
6040
2071
6173
475
475
6172
45
6019
5739
6225
45
5778
5742
475
6007
1435
5900
6230
475
475
6137
475
6029
475
6165
1774
6223
475
6106
2003
5871
1924
475
1884
950
475
1021
6018
2030
2060
1588
6231
5969
6035
475
1086
1145
475
475
475
5941
6082
6163
TRICARE EAST REGION
SELF PAY
6048
475
6162
6191
Tricare West
Medicare - Texas
Ambetter
UMR (formerly UMR Wausau)
VAPCCC Region 3
Medicare - Pennsylvania
Blue Cross Blue Shield of Texas
Web TPA / Community Health Electronic claims / CHEC
Sheet Metal Worker's National Health Fund SMW
Tricare
UHCP / UHC Dual Complete - Oxford Medicare Network
FIRST HEALTH - THE LEWER AGENCY
UNITED HEALTHCARE
Oscar Health
TRIWEST HEALTHCARE ALLIANCE PC3(VAPCCC REGIONS 1-6)
Tricare for Life HCFA
BCBS-Federal
UnitedHealthcare
Humana
Bankers Life
TRIWEST WPS MVH VAPC3
UnitedHealthcare West Encounters - Texas
Medicaid - Texas
Commonwealth Administrators, LLC
CIGNA HealthCare
Medicare Railroad
WellMed Healthcare
Health Texas Medical Group
705
2059
Mutual of Omaha
GEHA
Benefit Management Services
AARP MedicareComplete insured through UnitedHealthcare
State Farm Insurance Company
UnitedHealthcare / All Savers Insurance
6026
5666
Wellmed Medical
5741
6232
Gilsbar
Blue Cross Blue Shield of South Carolina(State Health Plan)
Blue Cross Blue Shield of Illinois
Care Improvement Plus (CIP)
USAA
MultiPlan GEHA
United States Automobile Association (USAA)
Humana MCD
CapRock Health Plan - Verity
Kempton Group Administrators
Texas Medicaid & Healthcare Partnership (TMHP)
6170
6087
1003
6119
6031
5989
6158
Medicare - Railroad
Continental General Insurance Company
MediShare (Christian Care Ministries)
AETNA MEDICARE
6050
Community First
WESTERN UNITED LIFE
Veterans Administration Patient Centered CCP Region 3
CHAMPVA - HAC
OXFORD MEDICARE NETWORK - AARP MEDICARECOMPLETE
CIGNA - PPO
Hartford
6147
New Era Employee Welfare Benefit
Colonial Penn Life Insurance
Health Cost Solutions
6117
PHCS GEHA
Humana Gold Plus
Capitol Administrators
Wellcare of Texas
Unicare
National Association of Letter Carriers (NALC)
Superior Health Plan (Ambetter) - Medical
Physicians Mutual Insurance Company
1168
5950
6097
Amerigroup Community Care
Group and Pension Administrators
Transamerica Life Insurance Company
1086
6097
Philadelphia American Life Insurance Company
American National Insurance Company (ANICO)
Humana Gold Choice
5677
Advantage Health Solutions
Molina Healthcare of Texas
CLOVER HEALTH (FORMERLY CAREPOINT HEALTH PLAN)
AARP Medicare Supplement Plans insured by UHIC
PIPA
Allied Benefit Systems, Inc.
1834
UnitedHealthcare / UHIS - UnitedHealth Integrated Services
Medicaid - Washington
..................................................
6072
Amerigroup Corporation
TRIWEST HEALTHCARE ALLIANCE PC3
FRIDAY HEALTH PLANS
Maxor Administrative Services
90 DEFREE BENEFITS
UnitedHealthcare / UnitedHealthcare West
AFSA
MOAA MEDIPLUS
BSBC
UnitedHealthOne / UnitedHealthcare Life Insurance Company
Hartford Life Insurance Company
FRIDAY HEALTHPLANS
FRIDAY HEALTH PLAN
Sierra Health and Life (Claims)
Assurant Health Self-Funded (Allied Benefit)
Trustmark Insurance Company
Government Employees Hospital Association (GEHA)
vumi
UOLIC
Loyal American Life (Medicare Supplement)
Blue Cross Medicare Advantage PPO/HMO
UnitedHealthcare Medicare Solutions / Medicare Advantage
PAPER
AMERIGROUP
FRIDAY
UnitedHealthcare / All Savers Alternate Funding
HealthSmart Preferred Care
USAA LIFE
IMAGINE HEALTH
SBMA
WPS Health Insurance
N/A
Self Insured Services Company (SISCO)
Meritain Health
UPMC Health Plan
SUPERIOR INSURANCE SERVICES
UnitedHealthOne / Golden Rule
Indian Health Services/Veteran Affairs
TREST MARK
Optum / Salt Lake County (Medicaid)
INSURANCE BENEFITS SYSTEMS
TRANSAMERICA LIFE INSURANCE COMPANY (TLIC)
EMR
10000
United American Insurance Company
FMH Benefit Services, Inc.
International Benefit Administrator
PLANSTIN ADM PHCS
UNITED WORLD LIFE INS CO
Liberty Health Advantage
Tall Tree Administrators
LHS/MedCost Solutions LLC
CHAMPVA Claims
Fringe Benefit Management
TN
BCBS
Centene Corp
State Farm Insurance
MANHATTAN LIFE INSURANCE COMPANY
UNITEDHEALTHCARE MEDICARE SOLUTIONS / UNITEDHEALTHCARE MEDICARECOMPLETE (FORMERLY SECUREHORIZONS)
DIRECT CARE ADMINISTRATORS
SELMAN AND COMPANY
Umited health care
Blue Cross Blue Shield of Nebraska
UnitedHealthcare Medicare Solutions / MedicareComplete
AMA Insurance Agency
EMI Health
Address2
Insurance Plan/Name
City
Insurance ID#
State
------Select-------
AL
AK
AZ
AR
CA
CO
CT
DE
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
TX
UT
VT
VA
WA
WV
WI
WY
Group ID#
Zip Code
Insured Name
Home Phone
Insured DOB (mm-dd-yyyy)
Cell Phone
Insured Relationship
Self
Spouse
Father
Mother
Other
Work Phone
Address
Email ID
City
Employer
State
------Select-------
AL
AK
AZ
AR
CA
CO
CT
DE
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
TX
UT
VT
VA
WA
WV
WI
WY
Emergency Contact
Zip Code
Emergency Phone
Medications
Aceon
Acidophilus
Aciphex
Active B 12
Actoplus Met
Actos
Adalat CC
Add Zantac otc 150mg 1-2 tabs at noon and before bed as needed.
Advair
Advicor
Advil
Advil Migraine
Afeditab CR
Agenerase
Aggrenox
Agrylin
albuteral inhaler
Aldactizide
Aldactone
Aleve
Align
Alinia
Alka Mints
Alkets
Alkums
allegra
Allopurinol
Aloxi
Alprazolam
Altace
Altoprev
Amaryl
Ambien
Amerge
Amilac
Amiloride/HCTZ
Amitiza
Amitone
Amitriptyline
Amlodipin/Atorva
amlodipine
amlodipine/benazepril
Amoxil
Ampicillin
Ampicillin injection
Anacin-3 Maximum Strength
Analpram-HC
Anastrozole
Ancef
Angiomax
Antara
Antispas
Antispasmodic
Antivert
Anusol-HC Cream
Anzemet
Apidra
Aplizine
Apresoline
Apriso
Aptivus
Aralen
Aricept
Arixtra
Armour Thyroid
Asacol
Asacol HD
ASFAGg
ASFAGGGGGS
Aspirin
Astelin
Astepro Nasal Spray
Atacand
Atacand HCT
Atenolol
Ativan
Atorvastatin
Atripla
Atrovent Inhaler
Augmentin
Augmentin ES-600
Augmentin XR
Avalide
Avandamet
Avandaryl
Avandia
Avapro
Avelox
Avinza
Avoid NSAIDs, prefer Tylenol prn pain instead
Avoid NSAIDs; Tylenol preferred prn pain
Avoid stimulant laxatives including herbals reviewed in detail with patient
Axert
Axid
Axocet
Azathioprine
Azulfidine
Azulfidine EN
B 12 inj
B 6
B1
Bactrim
Bactrim DS
Baraclude
Barbidonna
Bayer Aspirin
Bayer Aspirin Childrens
Bayer Aspirin Regimen
Bayer Aspirin Regimen with Calcium
Bayer Extra Strength
Benadryl
Benicar
Benicar HCT
Benifiber
Bentyl
Biaxin
Biaxin XL
Bidil
Bio identical liquid w/ vit D3
Biotin
Bisorprol
Boniva
Bowel prep: Magnesium citrate/Bisacodyl
Bowel prep: VA already mailed to pt home: GoLytely + bisacodyl - pt advised to follow our office instructions.
Bumetanide
Bumex
Buspar
Byetta
Bystolic
Caduet
Cal Oys
Cal-D,Mg,Zinc
Cal-Gest
Calan
Calan SR
Calcarb
Calci Mix
Calci-Chew
Calcitab
Calcium
Caltrate
Caltro
Camilla
Canasa Suppositories
Capoten
Captopril
Carafate
Cardene
Cardene SR
Cardizem
Cardizem CD
Cardizem LA
Cardura
Cartia XT
Carvedilol
Catapres
Catapres-TTS
Ceclor CD
Cedax
Cefaclor
Cefaclor ER
Ceftin
Cefzil
Celebrex
Celexa
Cellcept
Cenestin
Centrum Silver
Childrens Mylanta
Chlordinium
Cholestyramine Suspension
Chooz
Cilostazol
Cipro
Cipro Oral
Cipro XR
Citracal
Citrucel
Citrucel SF
Clarinex
Claritin
Cleocin
Clindamyacin
Clindex
Clorazepam
Clorpres
CO Q 10
Colace
Colchicine
Colchicine/Probenecid
Colestid
Colyte
Colyte w/ Flavor Packs
Colyte-Flavored
Combipres
Combivent
Combivir
Combunox
Compazine
Constilac
Constulose
Continue PPI daily regimen for total of 3 months then may change to as needed, discontinue, or continue daily dosing - pt. preference.
Continue to avoid NSAIDs
Copegus
Cordarone
Coreg
Coreg CR
Corgard
Cortef
Cortizone 10
Corzide
Coumadin
Covera-HS
Cozaar
Crestor
Crixivan
Cubicin
Cymbalta
Cytomel
Cytotec
Cytovene
D3
Darvocet-N
Darvon
Decadron
Demadex
Demerol Oral
Depakote
Depo-Medrol
Dexamethasone
Dexilant
Diabeta
Dialtizam
Dicarbosil
Dicyclomine
Diflucan
Digestive Advantage Gas Defense
Digitek
Dilacor XR
Dilantin
Dilatrate-SR
Dilaudid
Dilaudid-HP
Diltia XT
Diltiazem
Diovan
Diovan HCT
Discontinue NSAIDs - recommend Tylenol as needed for pain.
Dispermox
Diuril
docusate senna
Dolophine
Donnapine
Donnatal
Donnatal Extentab
Donnatal Extentabs
Duetact
Dulcolax
Duragesic
Duricef
Dyazide
Dynacin
Dynacirc
Dynacirc CR
Dyrenium
E.E.S.
Ecotrin
EES
Effexor XR
Elixiral
Elonazepam
Emend
Emtriva
Enalapril
Enbrel
Endur-Acin
Entocort
Enulose
Enzone
Epivir
Epivir-HBV
Epzicom
Equate stool softner
Equilet
Eraxis
Ery-Tab
Eryc
Erythrocin
Esidrix
Estradiol
Estrogen
Evista
Excedrin Back & Body
Excedrin Migraine
Exforge
Exforge/hctz
Exubera
F/U 1 yr PPI refill and prn
Factive
Famotidine
Famvir
Felodipine ER
Femhrt
Fenofibrate
Fentanyl
Ferro Secquels
Ferrous Sulfate
Fiber supplement
Fiber supplements
Fioricet
Fioricet with Codeine
Fiorinal with Codeine
Fiortal w codeine
fiortal with codeine
Firmagon
Fish Oil
Flagyl
Flecainde
Flecainide
Fleet Bisacodyl
Flexeril
flomax
Flonase
Flora Q
Florastor
Floxin
Flumadine
Fluoxetine
Folic Acid
Fortamet
Fosamax
Fragmin
Freestyle lite strp
Frova
Fruit Paste
Furosemide
Fuzeon
Gaviscon otc before meals
Genuine Bayer Aspirin
Glipizide ER
Glucophage
Glucophage XR
Glucosamine Chondroitin
Glucosamine Chondrotin
Glucotrol
Glucotrol XL
Glucovance
Glumetza
Glycolax
Golytely
Grifulvin V
HalfLytely and Bisacodyl
HCTZ
Helidac
Heparin
Hepsera
Herbs
Hivid
Humalog
Humalog Mix 75/25
Humira
Humulin 50/50
Humulin 70/30
Humulin N
Humulin R
Hydralazine
Hydrochlorot cap
Hydrochlorothiazide
Hydrocodone/APAP
Hydrocortison AC
Hydrocortisone cream
HydroDIURIL
hydroxychloroquine
Hydroxyzine HCL
Hyomax DT
Hyosophen
Hytrin
Hyzaar
Ibuprofen
Imdur
Imitrex
Imodium A-D
Inderal
Inderal LA
InnoPran XL
Inspra
Integrilin
Intron A
Iron
ISMO
Isoniazid
Isoptin SR
Isordil
Isordil Titradose
Isosorbide Dinitrate
Isosorbide Mononitrate
Janumet
Januvia
K-Dur
Kadian
Kaletra
Keflex
Ketek
Klor-con
Konsyl
Kristalose
Kytril
Labetolol
Lactulose
Lamictal
Lamisil
Lanoxicaps
Lanoxin
Lansoprazole
Lantus
lantus solostar
Lariam
Lasix
Lescol
Lescol XL
Letairis
Levaquin
Levbid
Levemir
Levothyroxine
Levoxyl
Levsin
Lexapro
Lexxel
Lialda
Librax
Lidoderm
limbrel
linzess
Linzess samples 145 mcg/290mcg 1 tab 30min AC breakfast for constipation: start low dose then advance to higher if ineffective after 4th day. Call office if Rx preferred.
Lipitor
Lisinopril
lisinopril/ hctz
Loestrin
Lofibra
Lomotil
Lopid
Lopressor
Lopressor HCT
Lorazepam
Lorcet
Lorcet 10/650
Lorcet HD
Lorcet Plus
Lortab
Losartan
Lotensin
Lotensin HCT
Lotrel
Lotronex
Lovaza
Lovenox
Lozol
Lyrica
Maalox
Macrobid
Macrodantin
magnesium
Malarone
Marinol
Mavik
Maxalt
Maxalt MLT
Maxaquin
Maxzide-25
May add otc Zantac 150mg 1-2 tabs qhs prn
May change to otc and prn after 8-12 week post-EGD daily Rx dosing completed
Medrol
Melatonin
Meloxicam
Memor all
Mepron
Mercaptpurine
Mesalamine
Metaglip
Metamucil
Metanex
Metformin
Methadose
Metoprolol
Metoprolol XL
Mevacor
Mexiletine
Micardis
Micardis HCT
Micronase
milk titistle
Mimvey
Minipress
Minitran
MiraLax (polyethylene glycol) otc 17grams once daily (follow package instructions) as needed for constipation; if ineffective after 4 days, can add Colace (docusate) otc 100mg 1 tab by mouth once to twice daily.
MiraLAX daily x 14 days. Add Colace 100mg qd-tid after 1 week if ineffective. If still ineffective d/c above and start Linzess trial 145mcg take 1 tab 30min before breakfast, given 8 sample tabs- pt to call if Linzess effective and would like Rx or try higher dose.
Mobic
Moduretic 5-50
Monodox
Monopril
Monurol
Morphine
Motrin
Motrin Migraine
Moviprep
MS Contin
Multi Mature
Multi vits
MultiVitamin
Musinex
Myambutol
Mycostatin
Mykrox
Mylanta Gas Maximum Strength
Mylanta Gas Maximum Strength Softgels
Mylanta Gas Regular Strength
Mylanta Gelcaps Antacid
Mylanta Maximum Strength Liquid
Mylanta Regular Strength Liquid
Mylanta Supreme
Mylanta Ultra Tabs
Namenda
Naproxen
Nasacort
Nephro Calci
Neurontin
Nexium
Nexium - samples given
Niasin
Niaspan
Nifedipine
Nitrek
Nitro Patch
Nitro-Bid
Nitro-Dur
Nitroglycerin
Nitrolingual Spray
NitroMist
Nitrostat
Nizoral
None
Norco
Noroxin
Norpace
Norpace CR
Nortriptyline
Norvasc
Norvir
Novolin 70/30
Novolin N
Novolin R
Novolog
Novolog Mix 70/30
Nubain
Nulev
Nulytely
Nuva Ring
Nydrazid
Nystatin
Ocurite
Ocuvite
omega 3
Omeprazole 40 mg po qam at least 30 min. AC breakfast.
Omnicef
Omnipen
One A Day Vitamin
Onglyza
Opana
Opana ER
Orapred
Orencia
OsCal 500
Osmoprep
otc Prep H topical external hemorrhoidal pain/pruritus BID prn otc Prep H supp 1 PR qhs x 3 prn rectal bleeding
Oxyprosin
Oysco 500
Oyster Cal 500
Oyster Shell Calcium 500
Pamine Forte
Pantoprazole
Paroxetine
PCE
PCN
PEG-Intron
Pegasys
Penicillin VK
Pentasa
Pentazine
Pepcid
Pepcid AC
Pepcid Complete
Pepcid RPD
Persantine
Phenadoz
Phenergan
Phenergan (rectal)
Pindolol
Pink Magic
Pioglitazone
Plaquenil
Plavix
Plendil
Pletal
Potassium
Potassium Chl.
Potassium Chloride
Prandin
Pravachol
Pravastatin
Precose
Prednisone
Premarin
Prempro
Prenatal Vitamins
Prenatal vits
Preperation H gel
Prevacid
Prevacid IV
Prevacid Naprapac
Prevacid Solutab
Prevpac
Prezista
Pridostigmine
Prilosec
Prilosec OTC
Prinivil
Prinzide
Pristiq
Probenecid
Probiotic 4
Probiotics
Procanbid
Procardia
Procardia XL
Proctocort Cream
Proctocream HC
Proctofoam-HC
Proctosol HC
Proctozone-HC
Progestrine
Promacot
Promethazine
Promethegan
Pronutrients
Propanolol
Propylthiouracil
Proquin XR
Proscar
Protonix
Provera
Provigil
Prozac
Pt educated re: medication indication, dosing/administration, cautions/contraindications and possible adverse effects - pt verbalized understanding
Pylera
Pyrazinamide
Questran
Quinapril
Quinidine sulfate
Ramipril
Ranexa
Rebetol
Rebetron
Recommend 2nd generation antihistamine (Claritin, Zyrtec, or Allegra) once daily prevention seasonal allergies.
Refludan
Refresh Eye gtts
Reglan
Relenza
Relpax
Remicade
Remodulin
Rescriptor
Restasis eye gtts
Retrovir
Revatio
Reyataz
RhoGAM
Rhythmol
Rhythmol SR
Rifater
Riomet
Rocephin
Rolaids Sodium Free
Rowasa
Saw Palmetto
Sectral
Senokot
Septra
Septra DS
Seroquel
Sertraline
Simcor
simvastatin
Singulair
Slow FE
Sodium Bicar
Solodyn
Spasmolin
Spectracef
Spiriva Inhaler
Spironolactone
Split dose Prepopik and 5-day diet per OFFICE printed instructions.
Starlix
Start Nexium 40mg 1 po 30 min AC breakfast samples provided.
Start oral hydration 1-2 gallons on morning of bowel prep. (day -1) to include electrolyte drink.
Start psyllium fiber capsule otc 1 po QD x 2 weeks then increase to 1 PO BID and continue
Stool softener
Sular
Sulfatrim Pediatric
Sumycin
Suprax
Suprep
Sustenex
Sustiva
Symax
Symbicort Inhaler
Symlin
Symmetrel
Synercid
Syntest
Synthroid
Tagamet
take 1 tab once daily on empty stomach 30 min. to 1 hr. before eating
Tambocor
Tamiflu
Tamsulosin
Tapazole
Tarka
Taztia XT
Tekturna
Temazepam
Tenex
Tenormin
Terazosin
Testim 1% gel
Testoserone Cyprionate
Teveten
Thorazine
Thyrolar
Thyroxine
Tiazac
Ticlid
Tigan
Timolol
Tindamax
Tirosint
Tizanidine
Tobi
Topamax
Topiramate
Toprol-XL
Tramadol
Transderm Scop
Travatan gtts
Trazodone
Trental
Triamcinolone cream
Triamterene/HCTZ
Tricor
Trileptal
Trizivir
Truvada
tumeric
Tums
Tums Ultra
Tygacil
Tylenol
Tylenol
Tyzeka
Ultram
Uniretic
Unithroid
Univasc
Uroxatral
Vagifem
valacyclovir
Valcyte
valerian root
valsartan-hydrochlorothiazide
Valtrex
Valturna
Vancocin
Vantin
Vaseretic
Vasotec
Veetids
Ventavis
Verapamil
Verelan PM
Vfend
Viberzi
Vibra-Tabs
Vibramycin
vicodin
Viracept
Viramune
Viread
Visicol
Visken
vit c
vit c
Vit D
vit E
Vitamin B Complex
Vitamin B12
Vitamin B12 Injection
Vitamin B6
Vitamin D
Vitamin D3
Vitamin E
Vivelle Dot
Vytorin
Welchol
wellbutrin
Xalantan gtts
Xanax
Xanax
Xgeva
Xifaxan
Xopenex
Zanaflex
Zantac
Zantac OTC
Zaroxolyn
Zebeta
Zegerid
Zemplar
Zerit
Zestoretic
Zestril
Zetia
Ziac
Ziagen
Zinc
Zithromax
Zmax
Zocor
Zofran
Zofran Injection
Zolidem
Zoloft
Zolpidem
Zomig
Zonisamide
Zosyn
Zovia
Zovirax
Ztihromax
Zyprexa
Zyrtec
Zyrtec-D
Dosage
Direction
Allergies
Reaction
anaphylaxis
Rash
difficulty breathing, wheezing, chest tightness
loss of consciousness
hives, welts, or wheals
generalized erythema (redness)
swelling in the face, eyelids, lips, tongue, throat, hands, and feet
coughing, hoarseness
nasal congestion, sneezing
rapid or irregular heart beat
dizziness, faintness
tingling or sensation of warmth
difficulty swallowing
nausea, vomiting
diarrhea, abdominal cramping, bloating
anxiety, fear, feeling that you are going to die
confusion
depression
Medical History
Abdominal pain
Nose bleeding
scoliosis
Rheumatic Fever
Heart disease
Fibromyalgia
Hypothyroidism
Leukemia
Liver disease
Chronic fatigue
Hypertension
Bad Headaches
GERD
COPD
Rheumatoid Arthritis
Heart problems
Cancer
Bone, joint, or muscular problems
Cervical Cancer
Nervous breakdown
iron deficiency
Osteoporosis
High blood pressure
Psoriasis
hyperlipidemia
myelodysplastic syndrome
Headache
AVM, colonic
CAD
myelodysplastic syndrome
Depression
Positive FOBT
Hemorrhoids, internal
Stomach Ulcers
Chronic pain
Erosive esophagitis, Grade A
Diabetes
Anemia
Hepatitis C
diverticulitis
Asthma
Kidney Disease
Hepatitis A
hiatal hernia
Allergies
Joint Pain
Anxiety
Auto Immune Diseases
Emphysema
Chest pains
Unremarkable
epstein barr
Alzheimer’s disease
Abnormal EKG
Epilepsy
small bowel ulcer
High cholesterol
Sjogren's
Pneumonia
intestinal metaplasia
Vision problems
Pancreatitis
Stroke
Hemorrhoids, external
osteopenia
myasthenia gravis
Jaundice
Breast CA
GI bleed
Vomitting
Colitis
None
Back pain
Arthralgias, unspecified
Goiter
Prostate Cancer
Other
Surgical History
Date (mm-dd-yyyy)
Family History
Patient was adopted
If deceased, cause of death
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
100
101
102
103
104
105
106
107
108
109
110
Onset 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
100
101
102
103
104
105
106
107
108
109
110
Social History
Do you currently Smoke ?
Yes
No
No of Years
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
Number of packs per day
1
2
3
4
5
6
7
8
9
10
10 +
Do you drink alcohol ?
Yes
No
How much do you drink
Daily
Weekly
Are you pregnant ?
Yes
No
Other