NEW PATIENT REFERRAL 2024

PATIENT REFERRAL
Please send completed form with all relevant chart notes, demographics, insurance cards, images & test results
REFERRING PROVIDER INFORMATION
Date

MonthDayYear
Date
Referring Doctor*
Office Name*
Office Phone Number
Please enter a valid phone number.
Office Email
Please enter the best email address for your office (to be used for Newsletters). If you do not have one, please put info@info.com
PATIENT INFORMATION
Patient Name *

First NameLast Name
DOB*
Phone Number*
Patient Email
example@example.com
Insurance*
*Medical Group*
Authorization (please attach authorization)
*Sutter and Mercy require authorization from General Ophthalmology or PCP. **Medi-cal requires authorization from PCP. ***It is the responsibility of the referring doctor to request authorization.
REFERRAL INFORMATION
Which provider would you like to refer to?*

Jacob Brubaker, MDSamuel Lee, MDXiongfei Liu, MDPatricia Sierra, MDPeter Wu, MDPamela Wagner, MDFirst Available GlaucomaFirst Available CorneaNo Preference
PREFERRED OFFICE

SacramentoLincolnFolsom
REFERRAL URGENCY
*CO-MANAGEMENT ACKNOWLEDGMENT: PLEASE FILL OUT FOR EVERY REFERRAL*

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 inurance

YesNo
If recommended, I will co-manage MIGS

YesNo
TYPE OF REFERRAL*

Cataract EvaluationCornea EvaluationGlaucoma EvaluationKeratoconus EvaluationLASIK/PRK/ICL Evaluation- In Sacramento ONLYRefractive Lens Exchange EvaluationYAG Laser CapsulotomyOther
Previous LASIK/PRK?*

YesNo
If Yes, is refractive history available?*

YesNo
Glaucoma Evaluation

Opinion on management ONLYOpinion on management and careAssume glaucoma careConsider surgical therapy
Cornea Evaluation

Opinion on management ONLYOpinion on management and careAssume cornea careConsider surgical therapy
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REFERRING PROVIDER INFORMATION

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REFERRAL INFORMATION