Referral Guide One Vision. that wants great vision to be hassle-free, every day Yours. Also available online at eyeclinicwi.com/od-portal
Thank you for choosing the Eye Clinic of Wisconsin!
Referring your patient to the Eye Clinic of Wisconsin, SC Scheduling Tips Scheduling a patient for a Medical Consultation Complete the Request for Consult Form Copy both sides of insurance card(s) Fax all to the Patient Service Representative Fax Line at (715) 261-8665 A Patient Service Representative will contact the patient to schedule and fax an appointment confirmation to you. Scheduling a patient for a Cataract Surgery Consultation Complete the Referral for Cataract Surgery Form Copy both sides of insurance card(s) Fax all to the Patient Service Representative Fax Line at (715) 261-8665 A Patient Service Representative will contact the patient to schedule and fax an appointment confirmation to you. Please advise contact lens wearing patients that they should not wear their contact lenses for one week prior to the appointment Scheduling a patient for Special Testing Only - No Exam Complete the Special Testing Only Form Copy both sides of insurance card(s) Fax all to the Patient Service Representative Fax Line at (715) 261-8665 A Patient Service Representative will contact the patient to schedule and fax an appointment confirmation to you. All Form Masters and Instructions are Available at: www.eyeclincwi.com/od-portal/ Please call Liz Masanz, Optometric Liaison, at (715) 261-85300 with questions or concerns.
Physician Resource Site At the Eye Clinic of Wisconsin, we value our relationship with our optometric partners. In order to ensure ease with the referral process we have developed an additional tool for your use. At www.eyeclinciwi.com/od-portal/, you will find many features, including: Information about the Eye Clinic of Wisconsin s physicians and their specialties Office Locations The most up to date referral process and referral forms Calendar of Events Marketing Materials We invite you to explore today. Accessing the Site Go to www.eyeclinicwi.com/od-portal/ In order to log on to the Portal, enter: Username: localod Password: onevisionyours
Clinic Updates Fax Numbers In order to ensure a streamlined referral process, some of the fax numbers we have printed on our referral forms have changed. We apologize for any confusion this may have caused you and your staff. In order to expedite the referral process, we have assigned one number to use going forward. (715) 261-8665 Co-Managing If there are certain insurances that you cannot co-manage with or post-operative visits that you prefer the patient do at the Eye Clinic of Wisconsin, please let us know. We will add you to our list and manage your patients accordingly. Questions about billing or co-managing please call Liz Masanz at 715-261-8530. Communication you can anticipate for every patient you refer to the Eye Clinic of Wisconsin. 1. A faxed confirmation when the appointment is scheduled with appointment details: when, where, and who it is with. We try to schedule the patient within 24 hours of receiving your request. 2. A letter on the day of the evaluation from the surgeon with a summary and plan. 3. A surgery confirmation if surgery is scheduled indicating what has been scheduled, when, and where. 4. If co-managing you will receive a note on the day of surgery. 5. A Relinquish Letter if the patient is co-managed with the post op 1 day notes. 6. A Return to OD Letter if the patient is not co-managed with the final post op notes and refraction. If you do not receive one of these pieces of communication, please call Liz Masanz at (715) 261-8530.
Surgeon Specialty Surgery Types Locations Mathew W. Aschbrenner, MD Robert N. Beauchene, MD Douglas T. Edwards, MD Retina Laser Treatment; Retinal Detachment Repair; Retinal Tear Repair; Treatment for Macular Degeneration and Diabetic Retinopathy Rhinelander General Cataract/IOL; Yag Cap; Yag PI Antigo; Merrill; Medford Refractive Cataract/IOL; istent; Yag Cap; Yag PI; Refractive Kevin T. Flaherty, MD Cornea/Oculoplastics Cataract/IOL; Transplant; Pterygium; Yap Cap; Yag PI; Medical and cosmetic plastic procedures including Botox and Lid procedures Christopher M. Galang, DO Ferdinand M. Galang, DO Matthew G. Hattenhauer, MD Thaddeus J. Krolicki, MD Christopher J. Kucharski, MD Vernon C. Parmley, MD Oculoplastics/Pediatrics General/Oculoplastics Glaucoma Retina Glaucoma Cornea Medical and Cosmetic Plastic and Reconstructive Procedures including Botox, Juvederm, Brow and Lid Procedures; Pediatrics; Strabismus; Trauma Cataract/IOL; Yag Cap; Yag PI; Medical and Cosmetic Lid Procedures Cataract/IOL; Tube Shunt; Trabeculectomy; Yag Cap; Yag PI; SLT; ALT Laser Treatment; Retinal Detachment Repair; Retinal Tear Repair; Treatment for Macular Degeneration and Diabetic Retinopathy Cataract/IOL; Tube Shunt; Trabeculectomy ; Yag Cap; Yag PI; SLT; ALT Cataract/IOL; Transplant; Pterygium; Yap Cap; Yag PI Calvin D. Sprik, MD Refractive Cataract/IOL; Phakic IOL s; Yag Cap; Yag PI; Refractive Rhinelander; Medford Rhinelander; Antigo; Rhinelander; Stevens Point Rhinelander; Merrill; Medford Rhinelander; Stevens Point; Antigo Rhinelander; Stevens Point Rhinelander; Merrill; Wisconsin Rapids Antigo; Stevens Point; Wisconsin Rapids Rhinelander; Stevens Point David C. Tuman, MD General Cataract/IOL; Yag Cap; Yag PI Rhinelander; Antigo
Eye Clinic of Wisconsin Locations Wausau Office 800 N. First St Wausau, WI 54403 Rhinelander Office 2 E. Ocala St. Rhinelander, WI 54501 Stevens Point Office 3401 Stanley St. Stevens Point, WI 54481 Medford Office 101 S. Gibson St. Suite 16 Medford, WI 54451 Antigo Office 109 State Hwy 64 Antigo, WI 54409 Merrill Office 1207 O Day St. Merrill, WI 54452 Wisconsin Rapids Office 841 Goodnow Ave. Suite 103 Wisconsin Rapids, WI 54494
Staff Contacts Optometric Liaison Liz Masanz Questions regarding referral process, co-management, 715.261.8530 scheduling, general concerns. Surgical Director Kim Goddard Oversees all aspects of the ambulatory surgery center. 715.261.8750 Business Services Manager Margaret Kufalk Questions regarding patient scheduling, billing, and 715.261.8525 insurance verification and eligibility. Clinical Services Manager Paul Rovang Oversees all aspects of Medical Services area. 715.261.8529 Compliance Manager Lynn Patterson Questions regarding HIPPA and compliance. 715.261.8527 Surgical Services Manager Barb Lambrecht Oversees all aspects of Surgical Services. 715.261.8534 Refractive Surgical Program Cindy Frahm Questions regarding surgery, pre-operative arrangements, 715.261.8553 follow-up visits and eye examinations. Patient Service Representatives 800.472.0033 Schedule appointments, pre-operative arrangements and eye examinations.
Standard Post Op Schedules Cataract: Post op 1 day Post op 2-3 weeks Post op 2 must occur prior to the second eye surgery (if applicable) Lasik: Post op 1 day Post op 1 week can be canceled if stable at 1 day Post op 1 month Post op 3 months and 12 months *All post ops related to the surgery within the first year are included in their fee PRK: Post op 1 day Post op 4-5 days (SBCL removal) Post op 7-8 days Post op 1 month Post op 4-8 weeks and 12 months *All post ops related to the surgery within the first year are included in their fee
Standard Post Op Schedules DALK: Post op 1 day Post op 3-4 weeks K-transplant: Post op 1 day Post op 3-4 weeks Retina: Post op 1 day Post op 1 week Post op 1 month Retina Laser/Cryo: Post op determined by patient need
Date: Clinic Name Doctor Name Street Address City, State Zip Phone: 715.999.9999 Fax: 715.999.9999 Referral Form for Cataract Surgery Biometry Keratometry Post LASIK pt. Dr. Signature Dear Doctor:, Surgeon s Name An appointment has been requested for the following patient to see you in your office in, for consideration for cataract surgery in the right / left / both eye(s). (Location) Name: DOB: / / Address: State Zip Telephone: The most recent examination was on / /. Alternate Number: Visual Complaints: Most Recent Refraction: Sphere Cylinder Axis Prism Base Add Best Corrected Visual Acuity OD 20/ OS 20/ Applanation Tensions: OD/ OS x x Optional Additional Information: PAM: 20/ OD 20/ OS BAT (High): 20/ OD 20/ OS Other Pertinent Information/Ocular History: Physician s Signature It is my desire to have Dr., my own optometrist, perform my follow-up care after my cataract surgery. I have discussed this with Dr., and he/she has assured me that he/she is qualified to handle my postoperative care. I have been assured that you will be contacted immediately if I experience any complications related to my cataract surgery. Patient s Signature SAMPLE APPOINTMENT SCHEDULING Please call patient to schedule, note appointment below and fax back to my office. Please contact patient for billing information. I have already scheduled an appointment on the patient s behalf, as noted below: Date PSR Initials: Date: Time: Location: Provider:
Date: Clinic Name Dr. Name Street Address City, State Zip Phone: 715.999.9999 Fax: 715.999.9999 Request for Consultation PATIENT INFORMATION Additional Testing Required AVF External Photos OCT IOL Master Dr. Signature Patient Name: D.O.B.: If Minor- Guarantor s Name: Address: City: State: Zip: Phone #1: Phone #2: Insurance Plan: ID #: Self-Pay Referring Physician: Please fax clear copy of both sides of patient s insurance card CONSULT REQUEST I would like to have your assistance with this patient s care. Please evaluate this patient s ocular and visual complaints, and consider treatment as appropriate. I look forward to receiving your opinion and advice regarding care of this patient and would be happy to resume the general care of the patient following your consultation and treatment and/or recommendations, as appropriate. For Glaucoma Referrals please send a copy of the patient s: past visual fields, pressure readings, and a list of ocular medications. For Strabismus Referrals please include most recent refraction with prism if applicable. Please describe the condition(s) to be evaluated and past ocular history: Most Recent Refraction: Sphere Cylinder Axis Prism Base Add Best Corrected Visual Acuity If applicable SAMPLE x x Signature of Provider Requesting Consultation Signature: OD 20/ OS 20/ Date: Preferred Location: Preferred Ophthalmologist: Urgency APPOINTMENT SCHEDULING Please call patient to schedule, note appointment below and fax back to my office. Please contact patient for billing information. I have already scheduled an appointment on the patient s behalf, as noted below: PSR Initials: Date: Time: Location: Provider: Please fax this completed form to: (715) 261-8665
Please Note: Patient Name: Address: If an interpretation is requested, the patient must be seen by a Eye Clinic of Wisconsin physician. Please complete a REQUEST FOR CONSULTATION FORM, instead of this form. PATIENT INFORMATION Phone #1: Phone #2: Insurance Plan: ID #: Self-Pay Requesting Physician: Please fax clear copy of both sides of patient s insurance card Doctor s Signature: REQUESTING PROVIDER INFORMATION I would like to have your assistance with this patient s care. Please perform the special testing indicated below. Doctor s Name: NPI #: OD MD Practice Name: Practice Address: Practice Phone: Practice Email: ICD-9 Code: Glasses RX: Brief Clinical History: Practice Contact: Practice Fax: SPECIAL TESTING: REQUIRED INFORMATION DOB: Please fax a clear copy along with this form, and both sides of the patient s insurance card. SPECIAL TESTING REQUESTED Testing Type : Please Circle Designated Eye Wausau Rhinelander Stevens Point Antigo Merrill/Medford Please Circle Location A-Scan Immersion OD OS OU N/A N/A N/A IOL Master OD OS OU Stereo Photography Fundus OD OS OU N/A N/A Disc OD OS OU N/A N/A OCT (Ocular Coherence Tomography) OD OS OU N/A N/A Pachymetry OD OS OU SAMPLE Topography OD OS OU Humphrey OD OS OU N/A Pentacam OD OS OU N/A N/A N/A N/A Visual Field Sita Fast Humphrey 24-2 OD OS OU Standard Humphrey 24-2 OD OS OU Goldman Visual Field (Lids Only) OD OS OU N/A N/A N/A N/A Other: OD OS OU Please check all that apply: APPOINTMENT SCHEDULING Please call patient to schedule (and fax this form back as confirmation) I have already scheduled an appointment on the patient s behalf, as noted below Appt: Date: Time: Location: Provider: Please fax this completed form to: (715) 261-8665 A copy of the test results will be faxed to your office on the day of testing. The original test results will be mailed to you.
Low Vision Referral Low Vision Program Date: Dear Low Vision Specialist, An appointment has been made for the following patient to see you on the day of, 20, in your office for a low vision evaluation. Name: DOB: Address: State: Zip: Telephone: Most Recent Examination was on / /. Most Recent Refraction: SAMPLE Sphere Cylinder Axis Prism Base Add Best Corrected Visual Acuity OD 20/ OS 20/ Other Pertinent Information/Ocular History: Please fax this completed form to: (715) 261-8665 Physician s Signature
Date: 800 N First Street, Suite 100 Wausau, WI 54403 Ph: 715.298.5500 Dear Dr., Your patient,, D.O.B. had cataract surgery performed by Dr. today. The surgery went well and you will be seeing him/her tomorrow for their one day follow-up. If you have any questions or concerns, please do not hesitate to contact myself or my staff. Your patient had a Standard / Premium / Toric IOL (Axis ) placed in their right / left eye. Lens specifications are below. [Lens Sticker Here] Their target refraction, based on our lens calculations, is. Thank you for the opportunity to care for this patient. SAMPLE 800 N 1 st Street Wausau, WI 54403 Ph: 715.261.8500
Relinquish Letter Date of Report: Dear Doctor : An appointment has been made for to see you on. The patient understands that you will now assume responsibility of the postoperative care. The patient has been instructed to call us at any time if unable to reach you, for any reason. Cataract surgery was done on Right/Left eye Date by. SAMPLE Special circumstances at the time of surgery included: At the time of the last postoperative examination on, the uncorrected vision in the operated eye was 20/, improving to 20/ with. Applanation tension was. Other significant findings:. The following eye medications are being used:. Billing Co-Managed Care: Relinquish Care Date OD Assumed Care Date Number of days Diagnosis Code: Procedure Code: Please feel free to call with any questions or comments in regard to this patient s operative or postoperative course. The Eye Clinic physician on call is always available if you are unable to reach the surgeon who did the surgery. Thank you for asking the Eye Clinic of Wisconsin to share in the care of this patient. Sincerely, Eye Clinic of Wisconsin
Post-Cataract Assessment Report Patient: D.O.B. Last Name First Name MI Assessment Date: Procedure Date: OD OS Surgeon: Premium IOL: Crystalens* Tecnis MF* Restor* Toric AK LRI *= Please check Intermediate and Near Vision Brief HPI/CC: Uncorrected Visual Acuity: Dist OU 20 / Inter OU 20 / Near OU 20 / Keratometry Assessment OD Day/Week/Month OS Day/Week/Month Pd: Auto Refraction Manifest Refraction Uncorrected Visual Acuity: Dist 20 / Inter 20 / Near 20 / Flat K @Axis Steep K @ Axis Uncorrected Visual Acuity: Dist 20 / Inter 20 / Near 20 / Flat K @Axis Steep K @ Axis = 20 / = 20 / IOP Method: TA/DCT/NCT/TonoPen mmgh mmgh Time am/pm AC Cell Clear Trace +1 +2 +3 +4 Clear Trace +1 +2 +3 +4 Flare Clear Trace +1 +2 +3 +4 Clear Trace +1 +2 +3 +4 Posterior Capsule Ocular Medications Med: Frequency: Med: Frequency: Med: Frequency: Med: Frequency: Med: Frequency: Med: Frequency: Med: Frequency: Med: Frequency: Final Rx: Sphere Cylinder Axis Prism Base Add Tech: Scribe: x + SAMPLE x + Comments/Questions: Planned Follow Up Visit: OD Signature: Printed Name: Mail or Fax to: Eye Clinic of Wisconsin, S.C., 800 N. First Street, Wausau, WI 54403 Fax: 715.261.8665