Get the free Glaucoma Screening Exclusion Form - Meridian Health Plan

Glaucoma Screening Exclusion Form Member Name: Member ID#: Date of Birth: This member has had a diagnosis of glaucoma or glaucoma suspect. Date of diagnosis of glaucoma or glaucoma suspect: Please

How to fill out glaucoma screening exclusion form

How to fill out glaucoma screening exclusion form:

1. Obtain the glaucoma screening exclusion form from the appropriate source, such as your healthcare provider or the relevant organization.
2. Carefully read all the instructions provided on the form to ensure you understand the purpose and requirements of the exclusion form.
3. Fill in your personal information, such as your full name, date of birth, contact information, and any other details requested.
4. Provide information about your ophthalmologist or eye care provider, including their name, contact information, and any relevant identification numbers.
5. Indicate the reason for requesting exclusion from glaucoma screening. This may involve providing details about your specific condition, medical history, or other relevant factors.
6. If required, attach any supporting documentation or medical records that may be necessary to support your request for exclusion.
7. Review the completed form to ensure all information is accurate and complete. Make any necessary corrections or additions before submitting the form.
8. Follow the instructions provided on how to submit the form. This may involve mailing it to a specific address, submitting it electronically, or handing it in at a particular location.
9. Keep a copy of the completed form for your records, in case it is needed for any future reference or verification.

Who needs the glaucoma screening exclusion form:

1. Individuals with a documented medical history or condition that exempts them from undergoing glaucoma screening.
2. Those who have already been diagnosed with glaucoma and are receiving regular and appropriate treatment and monitoring from their ophthalmologist or eye care provider.
3. Patients who have undergone glaucoma screening in the past and have been determined to be at low risk for developing the condition, based on the results and recommendations of their eye care professionals.
4. Anyone who has been advised against glaucoma screening by a qualified healthcare professional due to specific medical reasons or concerns.

Please note that it is important to consult with your healthcare provider or eye care professional to determine if you are eligible for exclusion from glaucoma screening and to receive appropriate guidance regarding the use and completion of the exclusion form.

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