Eye MD Referral Form
Version November 2000
To: _________________, MD Fax____________ Date _______
From: _________________, MD/DO/NP Fax____________ E-mail ___________
Dear doctor, I have referred the following patient to you for an ophthalmologic examination.
Patient name __________________ Patient telephone ______________________
Diabetes: Most recent HbA1c _______ BP_____/_____
Please: CONTACT THIS PATIENT to schedule an appointment
Fax or mail your findings using the EyeMD Examination Report Form or your form.
Notify us by fax if patient refuses to schedule or no-shows
Patient refused to schedule appointment
Patient missed appointment and did not reschedule
Unable to contact patient
Our office has scheduled this patient on ________for the next diabetes visit. We would appreciate receiving
your findings PRIOR to this visit.
If plan referral required
Health Plan______________ Pt. ID ______________ Authorization number______________________
Number / Visit Type Authorized: __ Consult __ FU Visits __Diagnostic tests _________________ Surgery
Print-ready copies of the Eye MD Examination Referral Form and Eye MD Report Form can be obtained from
OMPRO 503-279-0100 or downloaded from the OMPRO Web site www.ompro.org.