Get the free Dougherty Laser Vision Referral Form

Dougherty Laser Vision Referral Form Date Patient Name Phone Number Email Address Insurance Referring Physician Phone Number Referral for (check all that apply) LAST Corneal Crosslinking Intact Cataracts

How to fill out dougherty laser vision referral

How to Fill Out Dougherty Laser Vision Referral:

1. Obtain the referral form: Start by obtaining the Dougherty Laser Vision referral form. This form is typically provided by your eye care provider or can be downloaded from the Dougherty Laser Vision website.
2. Personal Information: Fill in your personal information on the referral form. This includes your full name, date of birth, gender, address, phone number, and email address.
3. Referring Provider Information: Provide the information of your referring eye care provider. This includes their name, contact information, and any additional details requested on the form.
4. Insurance Information: Fill out the section pertaining to your insurance information. Include the name of your insurance provider, policy number, group number, and any other relevant details. If you have multiple insurance providers, ensure you provide the information for the primary insurance.
5. Patient Medical History: Complete the section on the referral form that requires you to provide your medical history. This includes any current medications, previous surgeries, known allergies, and any existing eye conditions or disorders. In some cases, additional space may be provided for you to provide further details.
6. Reason for Referral: Clearly state the reason for the referral to Dougherty Laser Vision. This could be for a specific eye condition or for a refractive surgery consultation. Be concise and provide any necessary details that will assist the specialists at Dougherty Laser Vision in assessing your situation.
7. Signature and Date: Ensure to sign and date the referral form. This confirms that the information provided is accurate and that you authorize the referral process.

Who Needs Dougherty Laser Vision Referral:

1. Individuals seeking advanced eye care: Those who are seeking specialized eye care services for various eye conditions or disorders may require a referral to Dougherty Laser Vision. This includes individuals with cataracts, glaucoma, corneal diseases, or refractive errors.
2. Patients considering refractive surgery: Individuals who are interested in undergoing refractive surgery, such as LASIK or PRK, may need a referral to Dougherty Laser Vision. Refractive surgeries aim to correct nearsightedness, farsightedness, or astigmatism, reducing the need for corrective eyewear.
3. Patients seeking a second opinion: Patients who have already received a diagnosis or treatment plan from another eye care provider may need a referral to Dougherty Laser Vision for a second opinion. This can help in exploring alternative treatment options or confirming the initial diagnosis.

In summary, filling out the Dougherty Laser Vision referral requires providing your personal information, referring eye care provider details, insurance information, medical history, reason for referral, and signing the form. The referral is typically needed by individuals seeking advanced eye care, those considering refractive surgery, or patients seeking a second opinion.

For pdfFiller’s FAQs

What is dougherty laser vision referral?

Dougherty Laser Vision referral is a form or document that must be filled out by individuals who are referring patients to Dougherty Laser Vision for vision correction procedures.

Who is required to file dougherty laser vision referral?

Any healthcare provider or individual who is referring a patient to Dougherty Laser Vision for vision correction procedures is required to file the referral.

How to fill out dougherty laser vision referral?

The referral form can typically be filled out online or through a physical form provided by Dougherty Laser Vision. It will require information about the patient, the referring individual, and details about the vision correction procedure.

What is the purpose of dougherty laser vision referral?

The purpose of the referral is to ensure that proper communication and documentation are in place between the referring individual and Dougherty Laser Vision, in order to facilitate the vision correction procedure for the patient.

What information must be reported on dougherty laser vision referral?

The referral form typically requires information such as patient demographics, medical history, reason for referral, referring individual's contact information, and any relevant documentation related to the patient's vision needs.

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