Get the free Diabetic Eye Exam Referral Form - The Humboldt IPA

Humboldt IPA Diabetes Eye Exam Referral and Report REFERRAL INFORMATION Referred By: Fax #: Referred To: Fax #: Reason for Referral: Patients Name: Date of Birth: Home Phone: Gender: M F Insurance:

How to fill out diabetic eye exam referral

How to fill out a diabetic eye exam referral:

1. Obtain the referral form: Contact your primary care physician or endocrinologist to request a diabetic eye exam referral form. They may have a specific form to use or can provide you with a general referral form.
2. Complete personal information: Fill out your personal information accurately on the referral form. This may include your full name, date of birth, address, phone number, and insurance information.
3. Include medical history: Provide any relevant information about your medical history, particularly information related to diabetes. This may include the date of diagnosis, type of diabetes, current medications, and any previous eye-related complications or treatments.
4. Specify reason for referral: Clearly state that you are seeking a diabetic eye exam and the reason for the referral. This could be a routine screening, monitoring for diabetic retinopathy, or any specific concerns you may have regarding your eye health.
5. Include additional information: Include any additional information that you believe is relevant, such as recent changes in vision, symptoms you may be experiencing, or any specific eye care preferences you have.
6. Obtain necessary signatures: Ensure that you sign the referral form where required. Additionally, if there are specific sections that need to be completed by your healthcare provider, make sure they fill them out accurately and sign the form as well.
7. Submit the referral: Once the form is complete, submit it as instructed by your healthcare provider. This may involve mailing it, faxing it, or delivering it in person to the designated office or eye care specialist.

Who needs a diabetic eye exam referral:

1. Individuals with diabetes: Anyone who has been diagnosed with diabetes, whether type 1 or type 2, should consider having regular diabetic eye exams. Diabetes can increase the risk of developing eye complications, such as diabetic retinopathy.
2. Those with diabetes-related risk factors: People who have had diabetes for several years, have difficulty controlling their blood sugar levels, or have high blood pressure and/or high cholesterol should be particularly vigilant about getting regular diabetic eye exams.
3. Pregnant women with diabetes: Pregnant women who have diabetes or develop gestational diabetes should also have regular diabetic eye exams. The changes in hormone levels during pregnancy can increase the risk of diabetic retinopathy.
4. Individuals with existing eye conditions: If you already have an eye condition, such as cataracts or glaucoma, in addition to having diabetes, your healthcare provider may recommend regular diabetic eye exams to monitor for any changes or complications.

It is important to consult with your healthcare provider to determine the frequency of diabetic eye exams and whether a referral is needed based on your individual circumstances.

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What is diabetic eye exam referral?

Diabetic eye exam referral is a recommendation for individuals with diabetes to have their eyes examined by an eye care specialist to check for any signs of diabetic retinopathy.

Who is required to file diabetic eye exam referral?

Healthcare providers managing the care of patients with diabetes are required to file diabetic eye exam referral.

How to fill out diabetic eye exam referral?

Diabetic eye exam referral can be filled out by healthcare providers and should include the patient's information, medical history, and reason for the referral.

What is the purpose of diabetic eye exam referral?

The purpose of diabetic eye exam referral is to ensure that individuals with diabetes receive regular eye exams to prevent, detect, and treat any diabetic-related eye conditions.

What information must be reported on diabetic eye exam referral?

Information such as patient's name, date of birth, contact information, medical history, reason for referral, and healthcare provider's information must be reported on diabetic eye exam referral.