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Get Diabetic Eye Exam Referral Form - The Humboldt Ipa
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How to fill out the Diabetic Eye Exam Referral Form - The Humboldt IPA online
This guide provides users with clear, step-by-step instructions on how to complete the Diabetic Eye Exam Referral Form for The Humboldt IPA online. By following these directions, you can ensure that the form is filled out correctly and submitted efficiently.
Follow the steps to accurately complete the form online.
- Select the ‘Get Form’ button to access the form and open it in your online editor.
- Begin filling in the referral information section. Start with the 'Referred By' field to enter your name or the referrer’s details, followed by the fax number. In the 'Referred To' field, provide the name and fax number of the specialist receiving the referral.
- Next, indicate the 'Reason for Referral'. This section is crucial for identifying the purpose of the referral.
- Enter the patient’s personal details in the subsequent fields. Include the patient’s name, date of birth, home phone, and insurance details.
- Mark the patient's gender using the provided options. Select either M (male) or F (female).
- Fill in the patient’s address to ensure proper communication and follow-up.
- In the report section, indicate the findings regarding retinopathy such as 'No Retinopathy', 'Mild', 'Moderate', or 'Severe' along with any specific details about the condition.
- Provide recommended treatments based on the patient's status, selecting from options like 'Ophthalmology Consult', 'Laser-Focal', or other recommended actions.
- Conclude the form with the clinician's name and date to finalize the referral.
- Once all fields are completed, you can save changes, download the form, print it for records, or share it as needed.
Complete your Diabetic Eye Exam Referral Form online today to ensure timely and accurate referrals.
Yes, diabetics require a specialized eye exam to monitor any changes in their eye health. This exam focuses on spotting early signs of diabetic retinopathy and other complications. Using the Diabetic Eye Exam Referral Form - The Humboldt IPA can help streamline this process and ensure you receive timely care.
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