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FAX COVER SHEET for Diabetic Eye Examination Report Patient Name_____________________________________DOB_______________________ Date of eye exam: _________________________ Thank you for seeing our patient and being a valuable provider of their Diabetic Eye Care. Please return completed form to: Crozer Medical Associates 1553 Chester Pike Suite 201 Crum Lynne, PA 19022 PCP ______________________________ Office: (610) 499-7180 Fax: (610) 876-0859 I give my permission to release this information to my PCP listed above. ____________________________ Signature __________________ Date Your patient was examined in our office on the above date and found to have the following findings in regard to the retinal examination. ______No diabetic retinopathy, OD_______OS______ ______Background diabetic retinopathy, OD_______OS______ ______Proliferative diabetic retinopathy, OD_______OS______ ______Other Ocular Conditions: Examiner’s Name _______________________________________________________________ Examiner’s Address _____________________________________________________________ Examiner’s Telephone Number ____________________________________________________ This facsimile may contain medical information. The medical information in this FAX message is confidential and protected by both State and Federal law. It is unlawful for unauthorized to review, copy, disclose or disseminate confidential medical information. If the reader of this warning is not the intended FAX recipient or the intended recipient’s agent, you are hereby notified that you have received this FAX message in error and that review and/or further disclosure of the information contained in the FAX is strictly prohibited. If you have received this FAX in error, Please notify me immediately at the telephone number indicated above and either destroy these documents or return the original by mail. Thank you