OHSU Casey Eye Institute Consultation Request Form 2019-2025 free printable template

Consultation Request Form The purpose of this form is to assist the provider with knowing whether this visit is to be billed as a consultation new patient visit or established patient visit. Patient name Address Date of birth Phone number h Patient Insurance Information Needs to be seen Urgent within 48 hrs For Evaluation Next Available Treatment Other please explain Evaluation and Treatment Patient Preliminary Diagnosis Symptoms or Signs This section should also be used to list any tests or...

How to fill out OHSU Casey Eye Institute Consultation Request

How to fill out OHSU Casey Eye Institute Consultation Request Form

1. Obtain the OHSU Casey Eye Institute Consultation Request Form from the official website or clinic.
2. Fill in the patient's personal information including name, date of birth, and contact details.
3. Provide relevant medical history, including previous eye conditions and treatments.
4. Include the referring physician’s details and reason for consultation.
5. Indicate any specific tests or evaluations you wish the specialist to perform.
6. Confirm that all information is accurate and complete.
7. Sign and date the form if required.
8. Submit the form via fax, email, or in person as per the OHSU guidelines.

Who needs OHSU Casey Eye Institute Consultation Request Form?

1. Patients needing specialized eye care.
2. Primary care physicians referring patients for specialist evaluation.
3. Optometrists seeking a second opinion or further assessment for their patients.
4. Individuals experiencing complex eye health issues.

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What is OHSU Casey Eye Institute Consultation Request Form?

The OHSU Casey Eye Institute Consultation Request Form is a document used by healthcare providers to refer patients to the Casey Eye Institute for specialized eye care and consultation.

Who is required to file OHSU Casey Eye Institute Consultation Request Form?

Healthcare providers, such as physicians or optometrists, who wish to refer patients for eye care services at the OHSU Casey Eye Institute are required to file this form.

How to fill out OHSU Casey Eye Institute Consultation Request Form?

To fill out the OHSU Casey Eye Institute Consultation Request Form, you must provide detailed patient information, the referring provider's information, reason for the consultation, and any relevant medical history or symptoms.

What is the purpose of OHSU Casey Eye Institute Consultation Request Form?

The purpose of the OHSU Casey Eye Institute Consultation Request Form is to facilitate the referral process for patients who need specialized eye care, ensuring that all necessary information is communicated effectively to the specialists.

What information must be reported on OHSU Casey Eye Institute Consultation Request Form?

The information that must be reported on the form includes patient demographics, the referring provider's details, the specific reason for the consultation, relevant medical history, and any current medications or treatments.