Express Eye Care: Eye Care Referral Form

NATIONWIDE • 888.539.0577


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Express Dental

Express Eye Care Referral Form

Contact us:
888-539-0577 (Phone)
888-539-0579 (Fax)
Email Us

Your Name:

Your Email:

Your Phone Nbr:		Your City:	Your State:
You are the :	The Adjuster The Nurse Case Manager Other

Patient's Name:
Date of Birth:		Date of Injury:		Claim Number:

Address:
Email:
City:	State:	Zip:
Home Phone:	Cell:

Employer Name:
Address:
City:	State:	Zip:
Work Phone:

Claimant's Job Title/Position:

If this is a litigated claim, please provide the Claimant's attorney information

Claimant's Attorney:
Attorney Address:
Attorney City:	State:	Zip:
Attorney Phone:

How did you learn about us?

Adjuster:		Phone:
Email:		Fax:

Case Manager:		Phone:
Email:		Fax:

How did injury occur?:
Chief Complaints?:

Referring Physician Name:
Phone:
Are there medical records we may review? How do we obtain these records?

Is there a script from a referring physician?
If yes, please list and include date & types:
Provider Name:
Location:
Phone Number:

	Evaluation & Treatment		Eye Glasses		Contact Lenses		Protective Eyewear		Replace Eye Glasses
	Onsite Vision Screening		2nd Opinion		IME		Peer Review		Replacement Lenses

Billing Information
Insurance Company:
Phone:
Address
City, State Zip:

Print a copy for your records
Email a copy of this referral to

Have a question about a particular eye case? Just give us a call, at 888-539-0577 or send us an email at info@expresshealthservices.com. Let Express Eye Care coordinate and make all the arrangements!