Download Referral Form to Mills Eye + Facial Surgery

+Crestview
+GulfBreeze
+Pensacola
182E.RedstoneAve.
Ste.A
Crestview,FL32539
1300ShorelineDr.
Ste.104
GulfBreeze,FL32561
6100N.DavisHwy.
Pensacola,FL32504
ReferralFormtoMillsEye+FacialSurgery
AppointmentRequestedwith:
OfficeLocationRequested:
Crestview
David M. Mills, MD, FACS
Comprehensive Ophthalmologist
Oculo-Facial Plastic, Reconstructive, and Cosmetic Surgeon
DavidM.Mills
DavidM.MillsMD,FACS
MD,FACS
Ophthalmologist+
Ophthalmologist+
FacialPlasticSurgeon
FacialPlasticSurgeon
SuzanneDay
SuzanneDayOD
OD
Optometrist
Optometrist
YourAppointment:
Date:
Time:
Location(circle):
+Ophthalmology
+OculoFacial
Crestview
PlasticSurgery
GulfBreeze
+FacialCosmetic
Surgery
Pensacola
+Optometry
+OpticalBoutique
+Ophthalmology
+OculoFacial
PlasticSurgery
+FacialCosmetic
Surgery
+Optometry
+OpticalBoutique
Suzanne Day, OD
Gulf Breeze
Pensacola
Optometrist
Patient’sDemographics:
DateofRequest:______________________________________
Name:___________________________________
DOB:_____________________________________
Phone:___________________________________
E-Mail:___________________________________
PrimaryInsurance:_____________________________
Policy#:_________________________________________
SecondaryInsurance:__________________________
Policy#:_________________________________________
ReferringDoctorInformation:
PrimaryCareDoctorInformation:
Name:____________________________________
NPI#:____________________________________
OfficePhone:____________________________
OfficeFax:_______________________________
Name:___________________________________________
NPI#:___________________________________________
OfficePhone:___________________________________
OfficeFax:______________________________________
ReasonforConsultation:
AnnualEyeExam
BlindPainfulEye(for
Enucleation/Evisceration)
Cataract
Co-ManagementDesired?
DermatochalasiswithVisual
FieldDefect
DiabeticDilatedEyeExam
Dry Eye / LipiFlowTreatment
Ectropion
Entropion
EyelidLesion
FacialCosmeticSurgery
(Botox,BrowLift,CO2Laser,
EyelidSurgery,Face/Neck
Lift,Fillers,Liposuction/Fat
Transfer)
FailedVisionScreening
Glasses/ContactLenses
Glaucoma/YAGPI
Orbital Disease / Graves’
PediatricOculoplastics
(Dermoid/Orbit,Congenital
Ptosis,Tearing)
PosteriorCapsular
Opacification/YAGPC
Pterygium
PtosiswithVisualFieldDefect
RefractiveSurgeryConsult
Tearing/Lacrimal
TraumatoEye,Lid,Orbit
Trichiasis
PatientInstructions/Information–PleaseREADTHIS:
1.Pleasebringthisformwithyou.
2.PleasebringALLcurrentinsurancecards.
3.Itisverylikelythatyoureyeswillbedilated
—pleaseBringaDriver.
4.Pleasebringacurrentlistofmedications,
currentglassesandcurrentcontactlenses.
5.Spaceislimited,sopleaseBringONLY1
driver/guestandleaveadditionalchildren
home.AnychildrenpresentmustNEVERbe
leftunattendedbytheirlegalguardian(s).
6.PleasebeadvisedthatMillsEye+Facial
Surgerycollectsallapplicableco-pays/
coinsurance,deductibles,andanybalance(s)
dueatthetimeofservice.
Phone[850]266+7500
www.MillsEye.com
7.Ifyouneedareferral/authorizationfrom
yourPrimaryCarePhysician/Insurance
Company,besuretoobtainonepriortoyour
visit.
8.ProceduresaretypicallyNOTperformedat
thesametimeastheevaluationdueto
insurancerestrictions.
9.Someproceduresrequirereturn
appointmentsfortestingtoobtain
preauthorizationduetoinsurance
guidelines.
10.WewillNOTseeminors(evenwithadult
siblingspresent)withoutthelegalguardian’s
writtenconsent.
Fax[850]390-4576
sendemailsto:[email protected]
Search“millseye”todownloadtheApp!
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