Clinical Provider Referral Form
Date of Referral
-
Month
-
Day
Year
Date
Clinic location to which you are referring your patient. If you are unsure of the location, please select the Commonwealth Clinic.
*
Commonwealth Clinic
Commonwealth Specialty Clinic
Roslindale Clinic
Patient Name
*
First Name
Last Name
Patient Date of Birth
-
Month
-
Day
Year
Date
Guardian Name (if patient is under age 18)
First Name
Last Name
Patient Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Insurance
Aetna
Blue Cross Blue Shield
Cigna
Commonwealth Care Alliance
EyeMed
First Health
GIC Indemnity
Harvard Pilgrim
Health Plans, Inc.
Humana Vision
Mass General Brigham
MassHealth plans (excluding Limited, Health Safety Net, Partial Health Safety Net, Health New England, Be Healthy Partnership)
Medicare Part B
Senior Whole Health
Tricare
Tufts Health Plan
United Healthcare
VSP
WellPoint (formerly Unicare)
WellSense (excluding bronze, gold, and platinum plans)
Other
Insurance Member ID
Referring Provider Name
*
First Name
Last Name
Name of Practice/Facility
Provider Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Fax Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Email
*
example@example.com
Reason(s) for Referral Request
General Eye Exam and/or Ocular Disease Care (annual exam, diabetic eye exam, floaters, flashes of light, conjunctivitis, red eye, etc.)
Specialty Contact Lens Service (Keratoconus, orthokeratology, dry eye, etc.)
Pediatric Care
Vision Therapy Services
Myopia Control Clinic
Low Vision Services
Other
Include any notes related to this case that may be necessary for this referral.
Please submit the following documents: patient demographic information; pertinent clinical notes; any additional relevant information.
Please note: To help us provide the highest level of care, all referrals to the Specialty Contact Lens, Low Vision, Vision Therapy, and Myopia Control clinics should include comprehensive eye exam records and a history of dilation. Missing information may delay the scheduling time frame for the referral appointment. Thank you for your cooperation!
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