Skip to main content
Book Exam
Map
Call Us
Menu
grafitti-brick-wall-overlay-purple
Home » Referral Request form – Medical Services

Referral Request form – Medical Services

Referral Request form – Medical Services

  • The above mentioned patient has presented the following condition(s);

    • H40.013; Open angle with borderline findings, low risk, bilateral
    • H35.3131; Nonexudative age-related macular degeneration, bilateral, early dry stage
    • H40.053; Ocular hypertension, bilateral

    Requesting referral for additional testing due to medical findings that require further treatment. Below is a list of procedures that will need to be performed.

    • 92133-Glaucoma OCT
    • 92134- AMD/HTN OCT
    • 92083 Visual Fields
    • 0509T ERG
    • 95930 VEP
    • 92014 Comprehensive Exam
    • 92285 External (Stereo) Photos
    • 92250 Fundus Photos
    • 92225 Extended Ophthalmoscopy
    • 92020 GONIOSCOPY
    • 92283 Color Vision Exam