Follow these steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the recipient’s name and medical title (e.g., MD or NP) in the designated field. Follow this with the sender’s name and medical title. Ensure both fax and phone numbers are correctly inputted.
3. In the report section, specify the name of the person examined along with the examination date.
4. For visual acuity, select the type of examination being performed (e.g., dilated or non-dilated retinal examination) and indicate the appropriate choices for fundus photography if applicable.
5. Enter relevant ICD codes in the designated area. Mark the findings based on the examination results, choosing from the provided options for diabetic retinopathy and indicating the affected eye if applicable.
6. Document any glaucoma findings, noting whether the condition is controlled or uncontrolled for each eye.
7. List current medications taken by the patient in the specified field. Select any relevant conditions such as glaucoma or narrow-angle glaucoma.
8. Report on cataracts, macular degeneration, or any posterior vitreous detachment as identified in the examination.
9. Outline the treatment performed during the visit by checking applicable services such as laser treatments or visual field exams.
10. Draft a plan for treatment, including follow-up intervals. Ensure that any necessary authorizations for treatments are marked and coded accordingly with ICD and CPT codes as needed.
11. Finally, input your name and date at the end of the form. Once all fields are completed, save your changes, download the form, and share or print it as required.

Start completing your documents online efficiently today.