SV FORMS

Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please fill this form out and bring it with you when you come in for your examination.

CONTACT LENS WEARERS: If you wear contact lenses, you have the choice to continue wearing them, including to your appointment, but please bring your glasses. You can also stop wearing your contact lenses for the 2 weeks prior to your appointment. This will allow us to take measurements of your eye at the time of your consultation. If you decide to keep wearing the contact lenses, and you are a candidate for surgery, you will be scheduled to return for the measurements later, when you have stopped wearing your contact lenses for 2 weeks.

Because of your vision, how much difficulty do you have with the following activities?

Check the box that best describes how much difficulty you have, even with glasses. If you do not perform the activity for reasons unrelated to your vision, circle "n/a"

Type a question

Rows	None	Somewhat	Moderate	Great Deal	Unable to do
Read small print
Read a book
Read a large print book
Recognize people when close to you
See steps
read traffic signs
Sewing
Writing checks
Playing bingo
Playing sports
Cooking
Watching TV
Day Driving
Night Driving

Patient Signature
SUPERIOR VISION
AUTHORIZATION REQUEST FORM
(or secure e-mail to ecs@superiorvision.com)
Member ID
Health Plan Name
Health Plan Product
Correspondence address
Referring Physician Healthplan ID
Referring Phone #
Format: (000) 000-0000.
OTHER PRIMARY INSURANCE INFORMATION
Medicare Primary Insurance?
Diagnosis RIGHT EYE
Diagnosis Left eye
Diagnosis Codes RIGHT EYE
Diagnosis Codes Left eye
Others relevant to requested procedure (indicate):
Date of Service

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Eye
CPT Codes (separate by commas)
Facility Name
ASC Address
Facility type
Facility Phone Number
REQUEST FOR EXPEDITED REVIEW OF URGENT CARE
*PLEASE INCLUDE MEDICAL RECORDS WITH THIS REQUEST*
Should be Empty: