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Eye Care Specialist, please: Complete this form Sign and date form Send completed form to ADVANTAGE o Fax: 317.663.1428 re: Diabetic Retinal Eye Exam Form o Mail: 9045 River Road, Suite 200, Indianapolis,
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01
Begin by gathering your personal information, such as your full name, contact details, and date of birth.
02
Provide details about your current eye-related concerns and symptoms. This may include any vision problems, eye discomfort, or family history of eye diseases.
03
Mention any previous eye surgeries or treatments you have had in the past.
04
Specify any medications or eye drops you are currently using.
05
It is important to provide your medical history, including any chronic health conditions, allergies, or medications you are taking.
06
If you have vision insurance, make sure to include your policy details for accurate billing.
07
Prioritize any specific requests or preferences, such as a particular eye care specialist or clinic location.
08
Double-check all the information you have provided to ensure accuracy before submitting the form.

Who needs an eye care specialist please?

01
Individuals experiencing vision problems, such as blurred vision, double vision, or difficulty seeing objects.
02
People suffering from eye discomfort, including itching, redness, dryness, or pain.
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Those with a family history of eye diseases, such as glaucoma or macular degeneration, that require regular check-ups.
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Individuals in need of prescription eyeglasses or contact lenses.
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Patients experiencing sudden changes in their vision or eye health.
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People with diabetes or other chronic health conditions that can affect eye health.
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Individuals seeking advice and guidance on maintaining good eye health and preventing eye-related issues.
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Those requiring specialized eye care, such as pediatric eye care, cataract surgery, or LASIK procedures.
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An eye care specialist is a healthcare professional who specializes in the diagnosis and treatment of eye-related issues.
Eye care specialists, eye care facilities, and healthcare providers are required to file eye care specialist forms.
Eye care specialist forms can be filled out online or submitted in person at the designated healthcare facility.
The purpose of the eye care specialist form is to report information related to eye care services provided to patients.
Information such as patient demographics, diagnosis, treatment provided, and billing details must be reported on the eye care specialist form.
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