Doctor Referral for Clinic

Please fax this form + copy of patient’s most recent eye exam + insurance cards to our secure fax line at 206-420-0951 OR submit online to lowvisionclinic@lhblind.org. Eye exam must have been conducted within the last 6 months.

If the patient needs a prior authorization (PA) to be seen, please start the process when you submit the referral. We will call to schedule the patient as soon as we receive all of the required paperwork.

Patient Name(Required)

First Last

Date of Birth

Address

Street Address Address Line 2 City State ZIP Code

Patient's Phone

Patient's Email(Required)

Preferred Contact Name and Number (if other than patient)

Reason for Referral/Key Presenting Problems (Client's main area of need)

Diagnosis

Visual Acuities: Distance

cc OD:

cc OS:

Visual Fields

Please fax the visual field results with the most recent eye exam, if available,. to: 206-420-0951

Will patient require any other low vision rehab services (O&M, OT, RT, etc)?

Yes

Referring Physician

Physician's Name

First Last

Physician's Address

Street Address Address Line 2 City State ZIP Code

Physician's Phone

Physician's Fax(Required)

Insurance Information

Primary Insurance Name(Required)

Primary Insurance Policy Number(Required)

Secondary Insurance Name(Required)

Secondary Insurance Policy Number(Required)

Has Prior Authorization been obtained?

Yes

If yes, please enter Prior Authorization number:

Comments

This field is for validation purposes and should be left unchanged.