Orbital and Plastic Surgery Consent (Addendum to General Consent)

Additional comments:

Patient (or person authorized to sign for patient)                                      Date

Witness                                                                                                          Date

Laser Surgery Consent (Addendum to General Consent)

Additional comments:

Patient (or person authorized to sign for patient)                                   Date

Witness                                                                                                          Date

After-Hours Contact Form and Recommendations

After-hours call recommendations and form

Making medical decisions on the basis of the limited information obtained over the telephone is a risky—albeit necessary—aspect of ophthalmic practice. Indeed, OMIC claims experience confirms that inadequate telephone screening, improper decision-making, and lack of documentation all play a significant role in ophthalmic malpractice claims.  Negligent telephone screening and treatment of postoperative patients is especially likely to result in malpractice claims.

Use our After Hours Screening Recommendations & Form to document these conversations and to inform physicians of care you have provided to their patients.

There are no open positions at OMIC at this time.

Comanagement FL specific- Consent and Patient Transfer Letter

Sample Patient Informed Consent to Co-Management of Postoperative Care

This will confirm that my surgeon has informed me that I have the right to be seen by him/her during the entire postoperative period. I have also been informed that I have the option to have my postoperative care co-managed by Dr. [OPTOMETRIST], an optometrist, if my surgeon determines that my postoperative condition is stable, that it is not medically necessary for my surgeon to continue to provide me with postoperative care, and that it is clinically appropriate for Dr. [OPTOMETRIST] to provide me with the postoperative care. I also understand that I can change my mind and return to my surgeon’s care.

I understand that, depending on the surgical procedure, all or only a portion of the fees may be covered by Medicare or my insurance company and that any remaining fees that are not covered will be my responsibility.  In addition, it has been explained to me that it is not possible to precisely predict the specific postoperative care services that will be provided to me. However, I have been informed that, assuming my recovery proceeds without complications, I can expect to be charged approximately the following fees if my postoperative care is not co-managed by Dr. [OPTOMETRIST]:

I have also been informed that, assuming my recovery proceeds without complications, I can expect to be charged approximately the following fees if my postoperative care is co-managed by Dr. [OPTOMETRIST]:

Finally, I have been informed that if my postoperative care is co-managed by Dr. [OPTOMETRIST], my surgeon and Dr. [OPTOMETRIST] each will provide me with an accurate and comprehensive itemized statement of the specific postoperative care services that they each provide along with the charge for each service.  [INCLUDE IF SURGERY COVERED IN WHOLE OR IN PART BY MEDICARE: I have been informed that I may receive additional statements and explanations of benefits from Medicare because the surgeon and the co-managing optometrist are both providing care.]

I understand that my surgeon will provide my postoperative care until my surgeon determines that it is no longer medically necessary for him/her to do so. I have discussed my choice with Dr. [OPTOMETRIST] and have been advised that it is clinically appropriate for Dr. [OPTOMETRIST] to provide the necessary postoperative care to me. Dr. [OPTOMETRIST] will send my surgeon, [Dr. SURGEON], a report after each visit. I have been assured that Dr. [OPTOMETRIST] will contact my surgeon immediately if I experience any problems or complications that arise related to my surgery, and I will be referred back to my surgeon if it becomes necessary.

After having been so informed, I [PATIENT NAME] voluntarily, knowingly, and willingly desire to have Dr.    [Optometrist], my optometrist, co-manage my postoperative care following my surgery.

The risks, benefits, and logistics of this co-management arrangement have been explained to me and I desire to proceed.

_____________________________ ______________

Patient’s Signature                                Date

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I have agreed to provide postoperative care for [PATIENT NAME] following surgery, and concur that the patient can expect that I will perform the projected postoperative services and charge the projected fees that are set forth above. I look forward to assuming the postoperative care, under the surgeon’s supervision, when the surgeon believes it is clinically appropriate to do so. I will keep the surgeon advised of the patient’s progress by sending written reports after each visit and will contact the surgeon immediately if the patient has any problems or complications that warrant the surgeon’s attention.

_____________________________ ______________

Optometrist’s Signature                         Date

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I acknowledge receipt of this fully completed and signed form.

_____________________________ ______________

Surgeon’s Signature                              Date

Sample Patient-Specific Transfer of Care Letter from Surgeon

[DATE]

Dear Dr. [NAME OF OD]:

On [DATE], our patient, [NAME], underwent successful cataract surgery[1] with implantation of a(n) [SPECIFY TYPE OF IOL] on his/her [SPECIFY OPERATIVE EYE (LEFT OR RIGHT) ] eye. My last postoperative visit with the patient was on [SPECIFY THE DATE] and his/her best-corrected vision was [INSERT].

Following the surgery, I performed an independent postoperative evaluation of [NAME] and determined that (i) his/her recovery from surgery has proceeded without complications and is expected to continue that way and (ii) it is not medically necessary for me to personally continue to provide the postoperative care. Furthermore, based on my independent review of your education, training, and experience, I have determined that it is clinically appropriate for you to provide continuing postoperative care to [NAME].

As you can see from the attached postoperative care consent form, I have informed [NAME] of the approximate fees that he/she can expect to be charged by me if I provide all of the postoperative care, and the approximate fees that he/she can expect to be charged by you and me if he/she consents to his/her postoperative care being co-managed. I have also informed [NAME] that if he/she consents to the co-management of his/her postoperative care, each of us will provide him/her with an accurate and comprehensive itemized statement of the specific postoperative care services that we each provide along with the charge for each service. Having been informed of the foregoing, [NAME] has consented in writing to the co-management of the postoperative care. Therefore, I am delegating my postoperative care responsibilities to you under my supervision. Enclosed please find a copy of the surgery report and the postoperative instruction sheet.

At this time, I am discharging [NAME] to your care and have asked him/her to make an appointment to see you in about [SPECIFY TIME PERIOD] . As indicated in the attached instruction sheet, please keep me informed of his/her progress after each visit and contact me if any complications or problems arise.

Sincerely,

[NAME OF SURGEON]