Risk Management



Referral Form for Managed Care Patients

REFERRAL FORM FOR MANAGED CARE PATIENTS

 

Date:                                                  

 

Dr.                                                        has referred you to Dr.                                              

 

Phone:                                                

 

This referral is:

                                          Emergency

 

                                           Urgent (24-48 hours)

 

                                           Timely (1-2 weeks)

 

                                           When convenient

 

This appointment will have to be made for you by your primary care physician,

Dr.                                                       , who has been notified.  If there are any problems scheduling this appointment, please contact this office.

 

For office use only:

 

Outcome:                                                                                                                                           

 

 

(Original to patient. Copy to chart.)

Please refer to OMIC's Copyright and Disclaimer regarding the contents on this website

Leave a comment



Six reasons OMIC is the best choice for ophthalmologists in America.

#6. Supporting your specialty.

OMIC was founded by members of the American Academy of Ophthalmology nearly a quarter century ago and is the only carrier sponsored and endorsed by AAO. OMIC is also endorsed by 40 other ophthalmic societies. The OMIC partnerships with state and subspecialty societies qualifies their members for an exclusive 8% premium credit. Contact your state society for details.

61864684