Get Pediatric Ophthalmology Referral Form 081915 - Columbiaeye

Filling out the Pediatric Ophthalmology Referral Form 081915 is essential for initiating a referral to a specialist in pediatric ophthalmology. This guide provides step-by-step instructions to ensure users complete the form accurately and efficiently.

Follow the steps to complete the Pediatric Ophthalmology Referral Form online.

1. Click the ‘Get Form’ button to obtain the referral form and open it in your preferred online document editor.
2. In the 'Date of request' field, enter the current date to indicate when the referral is being made.
3. Fill in the 'Referring Physician' section with your name and contact number to ensure clear communication.
4. Under 'Diagnosis/Reason for Referral,' clearly state the medical reason for the patient's referral to a pediatric ophthalmologist.
5. In the 'Patient’s Name' section, write the last name followed by the first name exactly as it appears on the patient’s insurance card.
6. Indicate the patient's gender by selecting either 'Male' or 'Female.'
7. Fill in the 'DOB' field with the patient's date of birth and include the 'MRN' (Medical Record Number) if applicable.
8. Provide the 'E-mail' address for easy communication regarding the referral.
9. Enter the primary and secondary telephone numbers for the patient to ensure all contact avenues are covered.
10. Complete the 'Address' section with the patient's current residence to facilitate any necessary correspondence.
11. In the 'Guarantor Name' field, list the name of the individual responsible for the patient's healthcare costs, along with their date of birth.
12. Clearly state the primary and secondary insurance details, including company names and insurance IDs. If preferred, attach a copy of the patient’s insurance card.
13. Use the 'Comments' section to provide any additional notes or information that may assist the physician with the referral.
14. If required, attach any necessary insurance authorization form as specified by the patient's insurance plan.
15. Once you have completed the form, ensure all details are correct. Then, save your changes, download the document, print it, or share it as needed.

Take the next step in managing your health by completing the Pediatric Ophthalmology Referral Form online today.