Referral Form
Mark as urgent
Is this a new referral?
Yes
No
First Name
*
Last Name
*
Date Of Birth
*
Phone
*
Email
FILES (Demographics, Chart notes, and Insurance cards)
*
Medical Records are uploaded to a secure, HIPAA-compliant portal.
Referring Doctor Comments
Insurance Carrier
Insurance ID Number
Insurance Group Number
Previous LASIK/PRK
Yes
No
If Yes, is refractive history available?
Yes
No
Opinion on management ONLY
Assume glaucoma care
Consider Surgical Therapy
Glaucoma Fast-Track (DSLT) - IOP is < 26 on 0-2 drops
Goal:
Prevent drops
Stop drops
Reduce drops
I plan to follow the patient after the DSLT
Opinion on management ONLY
Opinion on management and care
Assume cornea care
Consider Surgical Therapy
COMMENTS/OTHER
CO-MANAGEMENT ACKNOWLEDGMENT:
*
YES - I'd like to co-manage the patient's post-op care if surgery is recommended and is medically appropriate.
NO - I do NOT wish to co-manage the patient's post-op care, if surgery is recommended, I'd prefer Sacramento Eye Consultants to assume the patient's post-op care and I will resume the general care of the patient after the post-op period.
I accept the patient's medical insurance
Yes
No
If recommended, I will co-manage MIGS
Yes
No
Referring Doctor Fax
*
Practice Email
Practice Name
*
Referring Doctor Name
*
Type of Referral
*
Cataract Evaluation
CPT Codes: 92004, 99202, 92082, 92134, 92136, 76519
Cornea Evaluation
CPT Codes: 92004, 99202-99205, 92025, 92082, 92132, 92285, 92286, 76514
Glaucoma Evaluation
CPT Codes: 92004, 99202-99205, 92020, 92082, 92083, 92133, 76514
Keratoconus Evaluation
LASIK/PRK/EVO ICL Evaluation
Sacramento Only
Refractive Lens Exchange Evaluation
YAG Laser Capsulotomy
Doctor Referring To
*
Please Select Doctor
Submit
