PATIENT REFERRAL
If patient needs an authorization or referral from PCP/Ophthalmology please send the referral to our office and the necessary provider for auth.
DATE
*
/
Month
/
Day
Year
Date
Urgency
Urgent
Not urgent
Patient Name
*
DOB
*
-
Month
-
Day
Year
Date
Phone Number
*
Email
example@example.com
Insurance
*
Medical Group
Mercy Medical Group & Woodland clinic require an auth from ophthalmologist. Sutter requires an auth from PCP or ophthalmologist.
Authorization
Mercy Medical Group & Woodland clinic require an auth from ophthalmologist. Sutter requires an auth from PCP or ophthalmologist.
Referring Doctor
*
Office Name and Phone Number
*
Office Email (to receive submission confirmation)
example@example.com
Refer to:
*
Jacob Brubaker, MD
Samuel Lee, MD
Xiongfei Liu, MD
Patricia Sierra, MD
Peter Wu, MD
Pamela Wagner, MD
First Available Glaucoma
First Available Cornea
No Preference
Preferred Office:
Sacramento
Lincoln
Folsom
Refer for:
*
Cataract Evaluation
Glaucoma Evaluation
DSLT-Fast Track: IOP is less than 26 on 0-2 drops
LASIK/PRK/EVO ICL Evaluation
Refractive Lens Exchange Evaluation
Keratoconus Evaluation
YAG Laser Capsulotomy
Cornea Evaluation
Other
COMMENTS/OTHER
Does the patient have a history of RK, LASIK or PRK?
Yes
No
If the patient has a history of refractive surgery is the information available?
Yes
No
Glaucoma Evaluation
Opinion on management ONLY
Assume glaucoma care
Consider Surgical Therapy
Goal for Glaucoma DSLT (Select all that apply)
Prevent drops
Stop drops
Reduce drops
I plan to follow the patient after the DSLT
Cornea Evaluation
Opinion on management ONLY
Opinion on management and care
Assume cornea care
Consider surgical therapy
Co-Management
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. 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
Please upload all relevant chart notes, demographics, insurance cards, images & test results
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