Get Exam Evaluation Form

Diabetes Retinopathy Evaluation In order for your exam to be covered under the medical benefit by Priority Health it must be completed by a participating eye care provider. Please ask your eye care provider to send a completed copy of this form to your primary care provider PCP. Diabetes Retinopathy Evaluation In order for your exam to be covered under the medical benefit by Priority Health it must be completed by a participating eye care provider. Please ask your eye care provider to send a completed copy of this form to your primary care provider PCP. It s very important for your PCP to have this information so be sure to take the form along to your next eye care visit. Patient Information Primary Care Provider PCP Information Date of birth Phone Date of Exam / Fax Findings No diabetic retinopathy is found in either eye OR Retinal Eye Exam abnormalities detected as follows Background changes noted in Right Circle Grade Mild Clinically Significant diabetic macular edema Left Circle Grade Proliferative changes noted in Active Moderate YES Severe NO Regressed/Stable Follow Up Routine follow-up exam is recommended in one year OR Follow-up of abnormalities in my office is recommended in timeframe. Referral to Dr. is recommended in Cataracts or Glaucoma detected OR laser treatment is needed* Letter to follow. Thank you for referring this patient for diabetic retinal evaluation* Sincerely Eye Care Provider s Signature Please fax or mail this document to the patient s Primary Care Provider identified above. For a list of participating eye care providers go to the Find a Doctor tool on priorityhealth. com* NCMS 1009WWWW 10/2008 4659A 04/09. Please ask your eye care provider to send a completed copy of this form to your primary care provider PCP. It s very important for your PCP to have this information so be sure to take the form along to your next eye care visit. It s very important for your PCP to have this information so be sure to take the form along to your next eye care visit. Patient Information Primary Care Provider PCP Information Date of birth Phone Date of Exam / Fax Findings No diabetic retinopathy is found in either eye OR Retinal Eye Exam abnormalities detected as follows Background changes noted in Right Circle Grade Mild Clinically Significant diabetic macular edema Left Circle Grade Proliferative changes noted in Active Moderate YES Severe NO Regressed/Stable Follow Up Routine follow-up exam is recommended in one year OR Follow-up of abnormalities in my office is recommended in timeframe. Patient Information Primary Care Provider PCP Information Date of birth Phone Date of Exam / Fax Findings No diabetic retinopathy is found in either eye OR Retinal Eye Exam abnormalities detected as follows Background changes noted in Right Circle Grade Mild Clinically Significant diabetic macular edema Left Circle Grade Proliferative changes noted in Active Moderate YES Severe NO Regressed/Stable Follow Up Routine follow-up exam is recommended in one year OR Follow-up of abnormalities in my office is recommended in timeframe. Referral to Dr. is recommended in Cataracts or Glaucoma detected OR laser treatment is needed* Letter to follow.