Referral Request Form for Tapadia Eye Care

Tapadia Eye Care

Referral Request Form
Date of referral

MonthDayYear
Date
- Patient name
- Patient phone number
  Format: (000) 000-0000.
- Date of birth
  
  MonthDayYear
  Date
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Patient's primary language
- Interpreter needed?
- Date of examination
  
  MonthDayYear
  Date
- Urgency of referral (Note: Please call us for urgent referrals.)
- Note: Please call us for urgent referrals.
- Diagnosis/reason for referral
- Self pay?
- Primary insurance name and type (PPO, POS, etc)
- Note: For CalOptima referrals, please use CPT 99205.
- Referring clinician's name
- Referring clinician's NPI
- Name of practice
- Practice phone number
  Format: (000) 000-0000.
- Practice fax number
  Please enter a valid phone number.Format: (000) 000-0000.
- Please attach all relevant exam notes, any relevant lab/testing results, and facesheet/demographics sheet.
  
  Cancelof
- Please click "Submit" to send your referral to our office securely. We will contact your patient to schedule an appointment.
  
  Thank you very much for your referral! We look forward to serving you and your patients.
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